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Full text of "The Pathology and treatment of venereal diseases [electronic resource]: including the results of recent investigations upon the subject"

Bu/Y)steac( 



THE 

ABNER WELLBORN CALHOUN 

MEDICAL LIBRARY 

1923 




Class. 



R 



Book 



PRESENTED BY 



s j_y\r^v<^- 




, PATHOLOGY AND TREATMENT 

VENEREAL DISEASES: * 



INCLUDING THE RESULTS OF RECENT INVESTIGATIONS - 
UPON THE SUBJECT. 



BY 

FREEMAN J. BUMSTEAD, M.E, 

LECTURER ON VENEREAL DISEASES AT THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK; LATE SURGEOH 
TO ST. LUKE'S HOSPITAL; SURGEON TO THE NEW YORK EYE AND EAR INFIRMARY. 



A NEW AND REVISED EDITION. 



WITH ILLUSTRATIONS 




PHILADELPHIA: 
HENRY C. LEA 
1866. 






Qf-XW 



Entered according to Act of Congress, in the year 1861, by 

BLANCHARD AND LEA, 

in the Office of the Clerk of the District Court of the United States in and for the 
Eastern District of the State of Pennsylvania. 



G4\ 



PHILADELPHIA : 
COLLINS, PRINTER. 



PREFACE TO THE FIRST EDITION, 



The object in the preparation of this work has been to furnish 
the student with a full and comprehensive treatise upon Venereal 
Diseases, and the practitioner with a plain and practical guide to 
their treatment. In carrying out this design, theoretical discussions 
have been made subordinate to practical details ; and, in the belief 
that the success of treatment depends quite as much upon the 
manner of its execution as upon the general principles upon which 
it is based, no minutiae, calculated to assist the surgeon or benefit 
the patient, have been regarded as unworthy of notice. 

The additions to our knowledge of Venereal, during the last ten 
years, have been numerous, and in the highest degree important. 
Among the most remarkable may be mentioned the distinct nature 
of the chancroid and syphilis ; the innocuousness of the secretion of 
the chancre when applied to the person bearing it, or to any indi- 
vidual affected with the syphilitic diathesis ; the removal of certain 
obstacles to a general belief in the contagiousness of secondary 
lesions; the fact that syphilis pursues the same course whether 
derived from a primary or secondary symptom, commencing, in 
either case, with a chancre at the point where the virus enters the 
system ; the definite period of incubation of the true chancre, and 
of general manifestations ; the inefficacy of the abortive treatment 
of syphilis ; and the phenomena of " syphilization," improperly so- 
called, and their correct interpretation. Several of these topics are 
entirely new within the period mentioned, and upon others much 
clearer 'views have been obtained ; so that our present knowledge 

(iii) 



IV PREFACE TO THE FIRST EDITION. 

of Venereal Diseases may be regarded as far more complete -and 
satisfactory than at any previous time. As yet, however, these 
results and the investigations which have led to them are, for the 
most part, scattered through the pages of medical periodical litera- 
ture, in our own and foreign languages. To collect them into one 
volume, and thus render them more accessible to the American 
reader, has also entered into the purpose of the author. 

New ioRK, July, 1861. 



PREFACE TO THE SECOND EDITION, 



The first edition of this work, the author is now free to confess, 
was published with many misgivings as to the reception it would 
receive. Presenting views directly at variance, in many respects, 
with those which were almost universally taught in our medical 
schools, and, with few exceptions, entertained by the profession at 
large throughout this country, it was natural to expect that it would 
meet with severe criticism and decided opposition ; with confidence, 
however, in the truth of the opinions advanced, the venture was 
made. 

Its success thus far has surpassed the most sanguine expectations 
of the writer. During a time of civil war, when communication 
with a considerable portion of our country has been suspended, and 
medical literature, except on military subjects, has been almost 
stagnant, a little more than two years sufficed to exhaust a large 
edition. The reviews of it, which have appeared both at home and 
abroad, have been in the highest degree gratifying. It has been 
thought worthy of translation and publication in Italy. Above all, 
the views set forth have steadily grown in favor ; their accuracy has 
been confirmed by time ; and they are now adopted by the chief 
authorities upon Venereal throughout the world. 

Of the credit of this success the author would gladly appropriate 

to himself the share of having presented in an acceptable manner 

(v) 



VI. PREFACE TO THE SECOND EDITION. 

to American readers the results of modern investigations relative to 
Venereal, and of having thus assisted in producing in this country 
the same remarkable and radical revolution of opinion that, within 
the last few years, has elsewhere taken place. To more than this, 
however, he would lay no claim. It was his good fortune to be the 
first writer, at least in English — and, it is believed, in any language 
— to embody the results referred to in a comprehensive treatise. 
A gap existed in medical literature, which it was impossible should 
long remain unfilled. Others undoubtedly would soon have accom- 
plished what he hopes to have done. He is well aware that by far 
the greater portion of the success of the work has been due to the 
original investigators, whose views are here given, and who have 
brought order out of the chaos that had for centuries prevailed. 
The truth, once indicated, was so plain and simple that every mind 
was ready to receive it, and to wonder that it had not been dis- 
covered before. 

The most noticeable change in the present edition will be found 
m the division of the work. From a certain deference to the 
opinions at that time generally received, the chancroid and its com- 
plications were, in the first edition, discussed in connection with 
syphilis. They have now been assigned, as is their due, to separate 
portions of the work. This change has necessitated a complete 
reconstruction of the second part of the first edition, and its division 
into two — a change which, it is hoped, will impress still more 
strongly upon the mind of the student the distinct nature of the 
two diseases referred to. The same object has been had in view in 
abandoning the terms "soft," "hard," "simple," and "infecting 
chancre," and in applying, in accordance with logical accuracy, the 
term chancre exclusively to the initial lesion of syphilis, and that of 
chancroid to the contagious ulcer of the genitals. The practical 
portion of the work has also undergone important alterations on 
various topics, among which may be mentioned the treatment of 



PREFACE TO THE SECOND EDITION. VU 

stricture by the " immediate plan " of Mr. Holt ; the abandonment 
of specific remedies in most cases of the initial lesion of .syphilis; 
the preference given to the external rather than the internal use of 
mercury in secondary and tertiary syphilis; and the necessity of 
trusting to nature, aided by hygienic influences, and not to treat- 
ment indefinitely prolonged after the disappearance of all syphilitic 
manifestations, to eliminate the virus from the system. Numerous 
emendations and additions of a minor character have been made , 
every portion of the work has been carefully revised ; a number of 
chapters have been rewritten ; several new illustrations have been 
added ; and no effort has been spared to render the present edition 
a complete treatise upon the subject of Venereal, thoroughly on a 
level with the most advanced state of our knowledge. It will be 
observed that by an increase in the size of the page, these additions 
have been accommodated without increasing the bulk of the volume. 

New York, May, 1864. 



CONTENTS. 



PAGE 

Introduction 17 



PART I. 

GONORRHOEA AND ITS COMPLICATIONS. 



CHAPTER I. 

Urethral Gonorrhoea in the Male 57 

Preliminary considerations 57 

Symptoms ..*....• 59 

Causes and nature of gonorrhoea 64 

Treatment 73 

Abortive treatment .......... 74 

Treatment of the acute stage 78 

Treatment of the stage of decline 82 

Copaiba and cubebs 89 

Obstacles to success . 96 

Treatment of special symptoms 98 

CHAPTER II. 

Gleet • ••••........ 101 

Symptoms 102 

Pathology 103 

Treatment 105 

Bougies . . . . 108 

Injections U0 

Deep urethral injections 112 

Blisters ' . . , m 113 

Separation of the affected surfaces • 114 

CHAPTER III. 

Balanitis ■ . * . 116 

Causes ••........ 116 

Symptoms ........ . 117 

Treatment ..*....... 11 

(ix) 



X CONTENTS. 

CHAPTER IV. 

PAGE 

Phymosis . . 120 

Symptoms 121 

Treatment . . . . . . • • . . . .. 1*2 

Circumcision 124 

CHAPTER V. 

Paraphimosis 128 

CHAPTER YI. 

Swelled Testicle .IB! 

Causes 132 

Seat " 134 

Symptoms 137 

Pathological anatomy 144 

Treatment 146 

CHAPTER VII. 

Inflammation of the Prostate 153 

Acute prostatitis 153 

Treatment . . . . . . . « . . . . 155 

Chronic prostatitis 156 

Treatment . . . . . 158 

CHAPTER VI LI. 

Inflammation of the Bladder 161 

Treatment 163 

CHAPTER IX. 

Gonorrhoea in Women 165 

Causes 165 

Symptoms 168 

Gonorrhoea of the vulva ......... 169 

Gonorrhoea of the vagina 172 

Gonorrhoea of the urethra 175 

Complications 177 

Diagnosis 178 

Treatment . 179 

CHAPTER X. 

Gonorrheal Ophthalmia 190 

Frequency ........•••• 191 

Causes 192 

Symptoms 194 

Diagnosis 197 

Treatment 198 



CONTENTS. 



XI 



CHAPTER XI. 



GONORRHEAL RHEUMATISM 

Causes • . 

Seat 

Symptoms 

Diagnosis 

Nature 

Treatment 



PAGE 

207 
209 
211 
213 
224 
225 
227 



Vegetations . 
Treatment 



CHAPTER XII 



230 
232 



CHAPTER XIII 

Stricture of the Urethra 
Anatomical considerations 
Transitory strictures 
Permanent or organic strictures 

Seat 

Number 

Form 

Degree of contraction 
Pathology of stricture 

Abscess and fistula . 

Lesions of the bladder 

Lesions of the ureters and kidneys 

Lesions of the genital organs 

Constitutional effects of stricture 
Symptoms of stricture 
Causes of stricture 
Diagnosis of stricture . . . 

Exploration of the urethra 

Introduction of the catheter 

Model bougies 
Treatment 

Constitutional means 

Dilatation 

Continuous dilatation 
Rapid dilatation 
Expansion 

Rupture ... 

Caustics . 

Incisions 

Internal division 
Perineal section 
Consequences of operations upon stricture 



234 
234 
251 
254 
257 
260 
261 
262 
265 
266 
268 
269 
269 
270 
271 
276 
281 
281 
285 
288 
289 
289 
291 
295 
296 
298 
298 
301 
304 
305 
310 
319 



XJ] 



CONTENTS. 



Treatment of retention of urine 

Puncture by the rectum 

Opening of the urethra 

Puncture above the pubes 

Puncture through the symphysis 
Treatment of extravasation of urine 
Treatment of urinary abscess and fistula 



PAGE 

322 

327 
330 
331 
331 
332 
332 



PART II. 

THE ( CHANCROID AND ITS COMPLICATIONS. 

CHAPTER I. 

The Chancroid 335 

Frequency 335 

Seat 336 

Contagion ... 338 

Inoculation ... 341 

Symptoms 342 

Diagnosis 345 

Treatment 347 



CHAPTER II. 

Special Indications from the Seat of Chancroids 
Chancroids upon the integument of the penis 
Chancroids of the frsenum .... 
Urethral chancroids ..... 

Chancroids of the female genital organs 
Chancroids of the anus and rectum 



356 
356 
356 
357 
358 
359 



CHAPTER III. 

The Chancroid complicated with Excessive Inflammation and with 

Phagedena 360 

Inflammatory or gangrenous chancroid ....... 360 

Phagedenic chancroids 361 



CHAPTER IT. 



The Chancroid complicated with Syphilis 



367 



CHAPTER V. 

Buboes 372 

Simple inflammatory bubo 373 

• Virulent bubo ........... 375 

Indolent bubo 377 



CONTENTS. 



Xlll 



PAGE 

Treatment of buboes 379 

General treatment 379 

Counter-irritants 380 

Compression ........... 381 

Methods of opening buboes 381 

Treatment of difficult cases 385 

CHAPTER VI. 

Lymphangitis 388 

PAKT III. 

SYPHILIS. 
CHAPTER I. 

INTRODUCTORY REMARKS 391 

S3 r philitic virus 391 

Syphilis commonly occurs but once in the same person . . . 392 

Exceptions to this law 393 

Syphilis possesses a period of incubation 395 

The order of evolution of syphilitic symptoms and the classification 

founded thereon . . 396 

CHAPTER II. 

The Initial Lesion op Syphilis, or Chancre 403 

Period of incubation 404 

Symptoms 407 

Diagnosis 416 

Urethral chancre .......... 418 

Buccal chancre . 418 

Treatment 419 

CHAPTER III. 

Induration of the Ganglia and of the Lymphatics .... 424 

Induration of the ganglia . 424 

Induration of the lymphatics 430 

Treatment 431 



CHAPTER IY. 

General Syphilis. — Introductory Remarks 432 

General syphilis always follows a chancre ...... 432 

Period of incubation ......... 434 

Some of the symptoms of general syphilis are contagious . . . 441 

What general symptoms are contagious ? ..... 456 

Syphilis pursues essentially the same course, whether derived from a 
primary or secondary symptom ; in the latter case, as in the former, 

the initial lesion is a chancre ........ 459 



XIV CONTENTS. 



CHAPTER V. 

PAGE 

Prognosis of Syphilis 466 

CHAPTER VI. 

Treatment of Syphilis . . 472 

Hygiene and tonics . . . . 473 

Mercurials 476 

Fumigation ........... 481 

Inunction ........... 484 

Salivation 485 

Duration of treatment ......... 489 

Iodine and its compounds . . . . . . . ... 492 

Vegetable decoctions and infusions 500 

Nitric acid 501 

CHAPTER VII. 

Treatment of Syphilis by Repeated Inoculation 502 

CHAPTER VIII. 

Syphilitic Fever; State of the Blood; Engorgement of the Lymphatic 

Ganglia 509 

Syphilitic fever 509 

State of the blood ........... 511 

Engorgement of the cervical ganglia . . . . . . . 511 

CHAPTER IX. 

Syphilitic Affections of the Skin 514 

Syphilitic erythema 518 

Syphilitic papules 520 

Syphilitic squamae ........... 521 

Syphilitic vesicles 523 

Syphilitic bullae 524 

Pemphigus 524 

Rupia 525 

Syphilitic pustules . 526 

Acne 526 

Impetigo 527 

Ecthyma 528 

Syphilitic tubercles 530 

Ulcers 534 

Treatment .534 

CHAPTER X. 

Syphilitic Affections of the Appendages of the Skin .... 537 

Alopecia ............ 537 

Onychia . . .......... 539 

Whitlow 540 



CONTENTS. XV 

CHAPTER XI. 

PAGE 

Mucous Patches 641 

Treatment 547 

CHAPTER XII. 

Gummy Tumors 548 

CHAPTER XIII. 

Syphilitic Affections of Mucous Membranes 551 

Erythema 551 

Ulcers ' 552 

Tubercles of the tongue 555 

Treatment of the affections of the mouth and throat .... 556 

Stricture of the oesophagus 558 

Affections of the stomach and intestines ...... 560 

Affections of the nasal passages 561 

Affections of the larynx and trachea 562 

Aphonia ............ 562 

Laryngitis ........... 563 

CHAPTER XI Y. 

Syphilitic Affections of the Eyes 568 

Affections of the bones of the orbit ....... 568 

Affections of the lachrymal passages 569 

Affections of the eyelids 571 

Affections of the conjunctiva 572 

Affections of the cornea . . . . . . . . . 573 

Iritis 574 

Infantile iritis 584 

Retinitis and choroiditis ......... 585 

Atrophy of optic nerve 587 

Hyperopia 587 

Paralysis of the motor nerves . . 588 

CHAPTER XY. 

Syphilitic Affections of the Ear 590 

CHAPTER XYI. 

Syphilitic Orchitis . . . . 593 

Diagnosis 595 

Treatment 597 

CHAPTER XYII. 

Syphilitic Affections of the Muscles and Tendons .... 599 

Muscular pains 599 

Muscular contraction 599 

Muscular tumors .... 601 



XVI ' CONTENTS. 



CHAPTER XYIII. 

PAGE 

Syphilitic Affections of the Nervous System . . . . 604 



CHAPTER XIX. 

Syphilitic Affections of the Periosteum and Bones .... 609 

Osteocopic pains 610 

Nodes 611 

Caries and necrosis , . 614 

CHAPTER XX. 

Congenital Syphilis 516 

Etiology 616 

Transmissibility 618 

Abortion 620 

Period of development 621 

Symptoms 625 

General aspect of syphilitic infants 625 

Coryza 626 

Affections of the skin and mucous membranes . . . . 626 

Onychia 628 

Suppuration of the thymus gland 628 

Changes in the lungs 628 

Changes in the liver , 629 

Peritonitis . . . . . . . . . t 631 

Affections of the periosteum and bones 631 

Hydrocephalus . . . 632 

Affections of the supra-renal capsules and pancreas . . . 632 

Prognosis 632 

Treatment 633 



VENEREAL DISEASES. 



INTRODUCTION. 

There are three diseases, which, from their origin in sexual 
intercourse, have been denominated Yenereal, viz. : Gonorrhoea ; 
the Contagious Ulcer of the Genitals, or Chancroid; and 
Syphilis. These three affections, for a long period confounded, 
have been, since the commencement of the present century, gradu- 
ally resuming the relations which they held to each other nearly ■ 
four hundred years ago. The medical mind has been travelling in 
a circle, and having completed the round, is now where it stood in 
the last part of the fifteenth and the first of the sixteenth century. 
The distinction between the above-named diseases which is now 
admitted — certainly by a very considerable number of our profes- 
sion, unsurpassed in intelligence, learning, and experience, and 
including names which have long been acknowledged as the highest 
authority — was fully recognized for twenty or thirty years after 
Columbus discovered the new world. 

The earlier history of venereal diseases has recently been very 
thoroughly investigated, especially by Bassereau, 1 Langlebert, 2 Cha- 
balier, 3 and Rollet,* and the conclusions which have uniformly been 
attained, startling as they may in some respects appear, are yet sup- 
ported by such an amount of proof drawn from the original sources, 

1 Affections de la Peau Symptomatiques de la Syphilis, Paris, 1852. 

2 Re'cherches Historiques sur la Doctrine Moderne des Maladies Ve'ne'riennes, 
1' Union MeU 1855. 

3 Preuves Historiques de la Plurality des Affections dites Ve"n6riennes, These de 
Paris, 1860 (No. 52). I am indebted to M. Chabalier's very able thesis for many of 
the following facts relating to the history of venereal diseases. 

* Recherches sur la Syphilis, etc., Paris, 1861. 

2 



18 INTKODUCTIOX. 

that they cannot be called in question ; at all events, they have not 
been disproved, although Bassereau's work has been for eleven years 
before the profession. I propose as briefly and concisely as possible 
to state what is at present known upon this subject. 

EARLY HISTORY OF GONORRHOEA. 

Gonorrhoea has existed among all nations, and from the earliest 
times of which we have any record. It is clearly referred to by 
Moses in the 15th chapter of Leviticus, where he lays down rules 
for the government of those who are affected with " a running issue 
out of the flesh." 

Among the Greeks and Eomans, gonorrhoea appears tG have been 
less common than among the Hebrews ; still, unquestionable traces 
of it are found. Hippocrates describes five kinds of leucorrhoea, in 
addition to discharges dependent upon inflammation of the womb, 
which are mentioned separately. Herodotus states that "the 
Scythians made an irruption into Palestine and pillaged the temple 
of Yenus Urania. The angry Goddess sent upon them and their 
posterity the woman's disease, which is characterized by a running 
from the penis. Those attacked by it are looked upon as accursed." ; 
Celsus 2 was also acquainted with balanitis and gonorrhoea; the lat- 
ter dependent, as he supposed, upon an ulcer within the urethra ; 
and Cicero says that " incontinence gives rise to dysuria, in the same 
manner that high living causes diarrhoea." 

At subsequent periods, this disease, and, in many instances, its 
complications of swelled testicle and cystitis, were described with 
more or less detail by Mesue 3 in 904; by Halli Abbas,* one of the 
Persian magi, who followed the doctrines of Zoroaster and wrote in 
980 ; by Ehazis, 5 a learned Arabian physician, born in Chorosana 
in 852 ; by Albucasa, 6 another Arabian of the eleventh century ; by 
Constantine of Carthage; 7 by Michael Scott 8 in 1214; by Gariopon- 
tus of Salerno ; by Eogerius, John Gaddesden 9 of England (com- 
mencement of fourteenth century); John de Concoregio, 10 John 

i Clio, lib. I. 

2 De Medicina, book vi., chap. 18. 

8 Summ. III., part 4, sect. i. 

* De Virgse Passionibus, Causis eorum et Signis, book ix., chap. 28. 

5 Rhazis, book X., chap. 3. 

6 Theoric. nee non Practic, tract, xxi., fol. 92 et 93. 

' Constantinus Africanus. De Morborum Cognitione et Cjjratione, lib. v. 

8 Michael Scott, De Procreat. Horn. Physion., Cap. vi. • 

9 John Gaddesden. Rosa Anglica, Practica Medicinse, a Capite ad Pedes, lib. ii., 
c. xvii., fol. 107. 

10 Practica nova Medicinse. Lucidur, tract, iv., fol. 66. 



INTRODUCTION. 19 

Arculanus, Guy de Chauliac, 1 Valescus de Tarento, John Ardern, 12 
settled at London in 1371 ; and by many others. Since the close of 
the fifteenth century, when the study of venereal diseases received 
new impulse from the irruption of syphilis into Europe, it is hardly 
necessary to state that every medical writer has been familiar with 
the existence of gonorrhoea. 

EARLY HISTORY OF THE CONTAGIOUS ULCER OF THE GENITALS. 

The history of the contagious ulcer of the genitals is essentially 
the same. Ulcers of the genital organs and suppurating buboes are 
described by nearly all the Greek, Latin, and Arabian writers on 
medicine. Hippocrates gives very minute directions for the treat- 
ment of abscesses, in the groin, dependent upon ulcerations of the 
womb and of the genitals. Celsus is still more explicit, and clearly 
describes the simple, phagedenic, serpiginous, and gangrenous vene- 
real ulcers, which are recognized, at the present day. It would be 
difficult, for instance, to draw up a more faithful description of the 
phagedenic chancroid than the following: "Ulcus latius atque 

altius serpit solet etiam interdum ad nervos ulcus descen- 

dere; profluitque pituita multa, sanies tenuis malique odoris, non 
coacta, et aquae similis in qua caro lota est ; doloresque is locus et 
punctiones habet." He also alludes to the danger of destruction of 
the prepuce when the ulcer is complicated with phymosis, and, 
under such circumstances, advises circumcision. Many other names 
might be quoted, but it is unnecessary to adduce farther evidence 
upon this subject, since it is generally admitted that ulcers of the 
genital organs dependent upon contagion in sexual intercourse, have 
been known from a very remote antiquity. The only point in dis- 
pute relates to their nature. 

It is maintained by some authors, and especially by Cazenave, 
that these were instances of primary syphilis, and not chancroids, as 
I have here assumed ; and they have been supposed to furnish evi- 
dence of the existence of syphilis in Europe*prior to the close of 
the fifteenth century. This idea is inadmissible for several reasons. 
One argument against it is the frequency of suppurating buboes 
with which these ulcers are said to have been attended ; since in the 

1 Cyrurgia Guidonis de Chauliaco, tract, vi., doct. ii. 

2 Becket, Philosoph. Trans., vol. xxx., p. 839. 

Most of the above texts have been derived from a learned work written in the last 
century by Gruner, and entitled : Aphrodisiacus sive de Lue Venerea in duas Partes 
divisus, quarum altera continet ejus Vestigia in Veterum Auctorum Monumentis 
obvia, altera quos Aloysius Luisinus temere omisit Scriptores, Jena, 1789. 



20 INTRODUCTION. 

great majority of true chancres the inguinal ganglia which become 
indurated remain entirely passive ; while the chancroid, on the con- 
trary, is frequently accompanied by an inflammatory bubo termi- 
nating in suppuration. This consideration, however, will have no 
weight with those who do not allow, in cases of venereal sores, any 
prognostic value to suppuration of the inguinal ganglia; but we 
can well afford to waive it and base our argument upon the fact that 
there is no record in history of the existence of general symptoms 
prior to the year 1494 ; that the ulcer of the genitals known to the 
ancients was always a local affection, and never followed by general 
manifestations at a distance from the point of contagion; that re- 
peated outbreaks of the disease when once apparently cured did not 
occur ; that hereditary syphilis was unknown ; * and finally, that the 
physicians who lived at the close of the fifteenth century, and who 
were perfectly familiar with the ulcers in question, were struck with 
horror and amazement at the appearance at this time of a disease 
which is now known to have been syphilis ; confessed that they had 
never seen its like before, and that they were ignorant of its nature 
and treatment ; and in their treatises upon venereal for nearly thirty 
years afterwards, described this and the former disease in separate 
and distinct chapters, thus showing that they did not entertain the 
least idea of their identity. 

•EARLY HISTORY OF SYPHILIS. 

According to the most reliable contemporary authors, syphilis 
was first known to European nations from its appearance in Italy 
in the latter part of the year 1494, about the time that Charles YIII., 
King of France, at the head of a large army, entered that country 
for the purpose of taking possession of the kingdom of Naples, to 
which he laid claim by right of inheritance. In this expedition, 
which was at first favored by the Neapolitans themselves, Charles 
left Eome on his way to Naples Jan. 28, and was received in the 
latter city Feb. 21, 1495. 2 The Neapolitans soon became restive 
under the yoke of their new master, and, assisted by the forces of 
Ferdinand of Aragon, under the leadership of Gonsalvo of Cordova 
the great captain, endeavored to expel the French from Italy. 

Now, although the new disease probably had no necessary con- 
nection with the events just mentioned, yet the latter doubtless 
favored the extension and exacerbation of the former through the 
license and debauch attending large bodies of troops, and subse- 

' Syphilis in infants at the breast is first mentioned by Gaspard Torello (1498). 
2 Guicciardxni, lib. i. cap. iv. 



INTRODUCTION. 21 

quently led to mutual recrimination between the natives and the 
invaders respecting the origin of the malady ; the French calling it 
" Mai de Naples," because it was to them unknown before the Nea- 
politan expedition, and the Italians ascribing its origin to the French, 
and calling it the " French disease." 

It is often asserted that the subsequent extension of syphilis was 
due to its conveyance to their homes after the close of the war by 
the troops which had been collected upon Italian soil. This could 
not, however, have been the sole, nor even the chief mode of its 
transmission ; since the French, on their return from Naples, fought 
the battle of Fornovo, July 6, 1495/ and a decree of Emperor Maxi- 
milian I., " Contra Blasphemos," promulgated at the Diet of "Worms, 
Aug. 7, of the same year, includes among the evils sent as a punish- 
ment against the prevailing vice of blasphemy, "praasertim novus 
ille et gravissimus hominum morbus, nostris diebus exortus, quern 
vulgo Malum Francicum vocant, post hominum memoriam inauditus, 
saeve grassatur, 2 thus showing that syphilis had already spread so 
widely in Germany as to attract general attention about the time 
that the French left Italy. 

Joseph Grunbeck, a German physician, writing in 1496, also de- 
scribes the disease as it appeared in his own person, evidently at a 
considerable period prior to the date of his work. This author 
states, as quoted by Chabalier, that he was a happy man until this 
new pestilence found its way into Germany ; but that one pleasant 
day while walking in the fields, he found himself attacked with it ; 
" et primam venenosam sagittam in glandem Priapi ista foetidas de- 
fixit, quae ex vulnere tumefacta, utrisque manibus vix comprehendi 
potuisset." Sad and dejected he returned home,, undecided whether 
he should make known his condition to his friends ; but the change 
in his countenance, his silence and despondency, made them suspect 
that some misfortune had occurred to him, and he was obliged at last 
to confess that he was attacked by the French disease, and to exhibit 
the evidences of it in his person. His dearest friends at once turned 
their backs upon him, and fled as if they had seen an enemy's sword 
suspended over their heads. Grunbeck's sadness was increased, and, 
retiring into solitude, he gave himself up to gloomy thoughts upon 
the vanity of earthly things and the ingratitude and perfidy of men. 
Meanwhile his disease extended, and a "thousand" ulcers appeared 
upon his penis and testicles and "vomited forth" bloody matter. 
After suffering in this manner for four months, he placed ^imself 
under the care of a celebrated empiric, who healed his sores by the 

1 Guicciaedini, lib. ii. cap. iv. 2 Goldast. Const. Imp. II. 110. 



22 INTRODUCTION. 

application of a powder which gave him much pain. The disease 
disappeared from the penis, but soon returned upon the skin, where 
it assumed the form of tubercles. "Pestifera qualitas ex hoc suppu- 
rato et arcto loco retrocessit, atque in multis aliis verrucas passim in 
cutis superficiem elisit." The skill of the most celebrated physicians 
was unable to dissipate these new symptoms. Temporary relief was 
obtained from frictions with an ointment containing mercury, which 
was recommended by a charlatan, but several relapses subsequently 
occurred. 

The testimony of other authors also concurs in showing that syphi- 
lis rapidly extended in the course of a few years over the greater 
part of Europe, and pervaded every rank of society. As stated by 
John Lemaire, a poet of that period : — 

II n' espargnoit ne couronne ne crosse. 

A large amount of evidence is adduced by Bassereau and Chaba- 
lier in support of the fact already mentioned that syphilis was en- 
tirely unknown prior to the year 1494. Its connection with sexual 
intercourse was not at first recognized, and many attributed it to the 
evil influences of the stars; and although a few endeavored to assi- 
milate it to certain diseases of ancient times, as, for instance, to the 
"asaphati" of the Persians, the mentagra which prevailed at Eome 
under Tiberius, to psoriasis, elephantiasis, and lepra, yet the greater 
portion of the writers of that period declared that it was entirely 
new in the world's history, and all confessed that, so far as their own 
experience went, they had never seen anything like it. 

For instance, Philip Beroald, who died in 1505, says that he can 
neither affirm nor deny the truth of the supposition that it has pre- 
viously existed ; all* that he knows with certainty is that this " French 
disease, characterized by enormous prominent spots, by pustules 
giving the face and body a hideous aspect, sometimes painless, at 
other times causing the most excruciating suffering in the joints, 
and depriving the patient of rest and sleep at night, slowly consumes 
the body ; that it can be cured by no remedy ; that it was unknown 
to his ancestors ; that whatever others may name it, he desir.es to call 
it morbum pestiferum diuturnum ; that he prays, Dii, prohibite mi- 
nas ! Dii, talem avertite pestem ! May this disease, more destructive 
than any pestilence, depart and return to the gulf of hell whence it 
came." 

James Cataneus de Lacu-Marcino, a Genoese, in his treatise de 
Morlo 'Gallico, written in 1505, states that in the year 1494, under 
the pontificate of Alexander VI., and during the invasion of Naples 
by Charles VIII., King of France, there appeared in Italy a terrible 



INTRODUCTION. 23 

disease, which was never before known in any age ; which was new 
to the whole world ; which did not resemble the asaphati nor any 
other serpiginous and fetid ulcer, and which could not be regarded 
as epidemic ; but which spreading over the world was due to the 
vengeance of God, who desires to punish fornication and adultery, 
which, though forbidden by law, are practised by men, who live 
like wild beasts. 1 The testimony of many other writers is equally 
conclusive. 

The contagious ulcers of the genitals which were known prior to 
the latter part of the fifteenth century, were called " caries," " caroli," 
and " taroli," and the first of these terms was afterwards applied to 
the new disease, which, however, was distinguished as the " caries 
gallica." Moreover, in the works of Marcellus Oumanus, Alexander 
Benedictus, Leonicenus, Gaspar Torella, John de Vigo, and other au- 
thors who wrote within thirty years after the appearance of syphilis, 
these two affections were described in separate chapters with many 
of the distinguishing features that are recognized at the present day. 
Thus, John de Vigo mentions the induration of those ulcers which 
are followed by constitutional symptoms : " Cum calositate eas cir- 
cumdante ;" and none of the writers of this early period, when speak- 
ing of the French disease, make any allusion to suppurating buboes, 
which are described apart and referred to the " caries non gallica" 
known in ancient times. An exceedingly accurate description is 
also given of the cutaneous eruptions, the nocturnal pains, the bony 
tumors, and other general symptoms of syphilis ; and notice is taken 
of the fact that a cure is in most cases only temporary, and that the 
disease often returns. Moreover, the early writers on syphilis be- 
lieved in the contagiousness of general symptoms, and even of the 
blood of infected persons, which has recently been demonstrated by 
actual experiment. 

ORIGIN OF SYPHILIS UNKNOWN. 

None of the theories which have been advanced to account for 
the appearance of syphilis in Europe near the close of the fifteenth 
century, rest upon sufficient data to entitle them to full credence. 
"We cannot suppose that it was of the nature of an epidemic and due 
to atmospheric influences, since it is expressly stated by those who 
witnessed its advent that it did not suddenly affect large numbers of 
persons of all ages, but spread from one to another, chiefly attacking 
jhe middle-aged (the very class most exposed in sexual intercourse), 
and sparing old men and infants, and the inhabitants of cloisters, and 

1 Chabalier, op. cit., p. 87. 



24 INTRODUCTION. 

that it advanced from Italy as a centre, and occupied several years 
in extending to the more remote countries of Europe. Moreover 
our present knowledge of the disease enables us to state with confi- 
dence that it never appears except as the result of contagion. 

The theory which has met with the most favor, refers the origin 
of syphilis to America, whence Columbus returning from his first 
voyage, landed at Barcelona, in Spain, in 1493, only a year before 
the appearance of the disease in Italy. According to Chabalier, it 
was stated by John Baptist Fulgosus, Doge of Venice, as early as 
1509, that a new disease, communicated only by coitus, and first af- 
fecting the genital organs, had broken out in Spain, and had thence 
been transported to Italy, and also that it came into Spain from 
Africa : " Quse pestis primo ex Hispania in Italiam allata, ad Hispa- 
nos ex ^Ethiopia, brevi totum terrarum orbem comprehendit." The 
idea that syphilis was brought to Europe from America by the sailors 
under Columbus was first advanced by Leonard Schmans, in 1518, 
Ulrich von Hutten in 1519, and Fracastori in 1521, with what evi- 
dence I shall proceed to show. 

There can be no doubt that syphilis existed in the colony founded 
by Columbus during his second voyage, but whether indigenous to 
the West Indies, or brought there by the Spaniards, is unknown. 
Washington Irving, in his Life and Voyages of Columbus, 1 says, 
when speaking of the colony at Isabella : " Many of the Spaniards 
suffered also under the torments of a disease hitherto unknown 
among them, the scourge, as was supposed, of their licentious inter- 
course with the Indian females ; but the origin of which, whether 
American or European, has been a subject of great dispute." Cha- 
balier also adds the following testimony : — 

Peter Martyr, Governor of Castile in 1492, states in a work 2 writ- 
ten in 1500 : " They have in this island (Hayti) a peculiar disease, 
characterized by large pustules occupying the body and eating into 
the extremities, because they are too much addicted to luxury. This 
disease is contracted by cohabitation with men and women who are 
already infected." 

Francisco Lopez de Gomare, almoner of Fernando Cortez, states 
that nearly all the Indians were affected with syphilis: "Los de 
aquesta isla Espannola son tudos bubosas, i como los Espannoles 
dormian con las Indias." 

Eodericus Diacius Insulanus, who was physician at Barcelona at 
the time syphilis made its appearance, is confident that it was brought 
to that city in 1493 by Columbus ; that the companions of Columbus 

1 Vol. i., book vi., chap. xi. 8 De Navigatione et Terris de Novo Repertis. 



INTRODUCTION. 25 

ascribed their disease to the privations and fatigue of the voyage ; 
and that at Barcelona they infected the entire city, whence the dis- 
ease was transported to Naples. When Charles VIII. arrived in 
Italy the following year, the opposing forces included a number of 
Spaniards affected with the disease, with regard to the nature of 
which they were ignorant, and which they attributed to atmospheric 
influences. 

Laying aside all Ariierican partialities, I have thus endeavored 
to give a truthful statement of the evidence upon this subject; 
which, as the reader will observe, contains no statement from those 
who took part in the discovery of the new world, that they found 
syphilis there on their arrival. Its existence in the Indies during 
the second voyage . of Columbus may readily be explained by its 
transportation thither by the Europeans, who may be supposed to 
have been quite willing to ascribe their disease to the natives. It 
is unnecessary, however, to enter into a farther discussion of this 
point, since I think I can assert with truth that those authors of the 
present day who have paid the most attention to this subject, regard 
the testimony in favor of the supposed American origin of syphilis 
as far from conclusive. Indeed, if credence is to be placed in a 
recent writer, 1 Chinese medical literature affords evidence of the 
existence of syphilis in that country and of its treatment by 
mercury, many centuries before the birth of Christ. 

The origin of syphilis, however, is enveloped in so much 
obscurity that we may well say, with Voltaire, "la verole est 
comme les beaux-arts, on ignore quel en a ete l'inventeur." 

AGE OF CONFUSION IN VENEREAL. 

The views that were entertained by those who witnessed the first 
appearance of syphilis in Europe, and which in many respects 
coincided to a remarkable degree with those which have recently- 
been advanced in the middle of the nineteenth century, gradually 
lost their hold upon succeeding generations, and were followed by 
the utmost confusion of ideas respecting this subject. A most 
admirable history of this " age of confusion in venereal," as it has 
been called, is given by Bassereau, which should be read by every 
one who would understand the origin of those errors from which 
the medical mind has but recently commenced to free itself, and 
which yet finds advocates among the profession. In justice to 
M. Bassereau, who was the first to discover the evidence afforded 

1 La flt^decine chez les Chinois, par le Capitaine Dabrt, Consul de France en 
Chine, etc., Parft, 1863. 



26 INTRODUCTION. 

by history in favor of the duality of the chancrous virus, I prefer 
to give the following extended extract from his remarks instead of 
a mere abridgment; and this course is the more desirable since 
the original discoverer ' is but little known in this country, and 
others have had the credit of his labors. 1 

" In the first part of the sixteenth century, a tendency to confound 
the various venereal diseases appeared. Thus, George Vella (A. D. 
1508) attributed them all to the same cause. The following is his 
line of argument : It is conceded, he says, that before the existence 
of the French disease, certain women communicated to men by 
coitus, ulcers which were never followed by that assemblage of 
symptoms which make up the new disease. But it is also certain 
that the latter commences with ulcers upon the- genitals, which are 
contracted in the same manner from diseased women, and have the 
same objective symptoms (quoad sensum visus) as the ulcers of the 
penis anterior to the appearance of the French disease, so that the 
most skilful physicians cannot distinguish them. If, then, these 
ulcers are contracted in the same manner, have the same aspect, 
and cannot be distinguished from each other, why not refer them 
to the same principle ? Vella admits that it may be objected that 
a new effect presupposes a new cause, and that since the French 
disease was never observed before, it must be produced by some 
other cause than the one to which we refer the contagious ulcers of 
the genitals which have been known in all ages. In answer to this 
objection, he replies, that the causes of disease may at times assume 
a greater activity, just as we see pestilential fevers produce greater 
ravages at certain periods than at others, while yet the cause 
remains the same. 

"It may also be objected, he says, that the necessity of new 
remedies indicates a difference in the nature of the disease. He 
replies, that it is indeed true that the remedies employed to cure 
the ulcers anterior to the French disease, are insufficient for the new 
disease, but that the means which are efficacious in the latter will 
also cure the former. This is equivalent to saying that the remedy 
of a severe disease is generally sufficient for a light disease, while 
the remedy of a light disease is not always the one required for a 
grave disease. 

1 In conversations with American physicians, I have been surprised to find many 
who were entirely unacquainted with the name of M. Bassereau, and who attributed 
the honor of producing the first proof in favor of the distinct nature of the 
chancroid and syphilis to M. Clerc, whose views, differing from Bassereau's and 
now known to be incorrect, were published two years later than Uiose of the last 
mentioned author. 



INTRODUCTION. 27 

" George Vella, therefore, very clearly establishes the fact, which 
we have seen to be apparent in the writings of Alexander Bene- 
dicts, Marcellus Cumanus, and John de Vigo, viz., the existence of 
contagious ulcers, the effects of which were confined to the genital 
organs, before the year 1495, and the appearance about this period 
of a new disease, which commenced upon the private parts in the 
form of ulcers, which were soon followed by general cutaneous 
eruptions, pains in the joints, etc. In addition to this — and the 
idea is entirely his own — he endeavors to show that these two 
affections are dependent upon the same cause. 

" It was not irrational nor inconsistent with pathology in Yella, 
to consider the new ulcers of the genitals which affect the whole 
system, as of the same nature as the local ulcers which were known 
in all ages, and to suppose that the latter had suddenly assumed an 
unusual activity under the influence of some peculiar state of the 
constitution. Unfortunately, his theory rests only upon two very 
contestable facts : 1. . The identity in their mode of transmission. 
2. Their striking resemblance and the impossibility of distinguishing 
between them. But it is evident that the same mode of communica- 
tion in two diseases does not prove their nature to be the same ; and 
Vella's supposed similarity in the appearance of all chancres had 
already been refuted by his predecessors. In fact, most preceding 
authors had agreed in their statements, that the ulcer which was fol- 
lowed by general symptoms, could be recognized by its livid aspect 
and its hard and indurated base ; and this ulcer appeared to them 
so different from the ordinary venereal sore that in their works upon 
venereal, they described it in separate books or chapters. 

" The writers on syphilis, whose testimony I have adduced in op- 
position to Vella's, did not say that the ulcer of the French disease 
always presented decided special symptoms ; nor do I myself attempt 
to sustain this opinion. In one of the preceding sections, I have 
shown that the characteristic induration is wanting in a number of 
venereal sores, followed by syphilitic erythema. 

" The doctrines professed by George Yella induced neglect of the 
study of the special symptoms of venereal ulcers, and greatly con- 
tributed to introduce confusion with regard to them. This confu- 
sion, however, was especially the work of those physicians, who had 
commenced the practice of their art subsequent to the year 1495, 
and who, therefore, were unable to compare the new disease with 
the venereal affections which had prevailed from time immemorial, 
before the close of the fifteenth century. In following the change 
which took place, we find that the first step was to make no distino- 



28 INTRODUCTION. 

tion in their writings between the old and new ulcer, and to include 
in their descriptions of syphilis certain complications which belong 
almost exclusively to the ancient variety. Thus Nicholas Massa 
(1532), the author of a celebrated treatise on the French disease, 
includes among the unequivocal symptoms of this affection, suppu- 
rating buboes, which attend almost exclusively the ulcer of the 
ancients. Yet it had not escaped the observing mind of Massa, 
that sores followed by suppurating buboes are rarely succeeded by 
cutaneous eruptions and other general symptoms; so that, after 
speaking of these buboes as a symptom of true syphilis, he is obliged 
to confess that patients who have them are generally exempt from 
the eruptions and pains which constitute the French disease. ' Et 
sequuntur apostemata inguinum quae si suppurantur removent 
segritudinem.' Matthiolus (1535) also includes suppurating buboes 
among the symptoms of the French disease. Antony Lecoq (A.D. 
1540) speaks of them in the same terms as Nicholas Massa ; whilst 
Fracastorius (A.D. 1530) and Sebastian Montius, both witnesses of 
the appearance and progress of syphilis, continue to describe this 
disease (the former in a special treatise, the latter in his 'Dialexeon' 
published in 1537, when he was eighty years old), as was done by 
Marcellus Cumanus, Benedictus, Leonicenus, Graspar Torella, and 
many others, without including suppurating buboes among its 
symptoms. 

" As the venereal ulcers of the ancients, and its attendant suppu- 
rating bubo, began to be included among the symptoms of syphilis, 
treatises on surgery ceased to contain those special chapters in which 
contagious ulcers of the genital organs and inguinal abscesses had 
heretofore been described. Discharges from the urethra were also 
included among the symptoms of syphilis, and still farther modified 
the tableau. Finally, in the descriptions given of the French dis- 
ease, not only were symptoms inserted which were completely foreign 
to syphilis, but the regular course of this affection was entirely 
forgotten. 

" This confusion was rendered complete by Anthony Musa Bras- 
savolus. This physician, who was a laborious student rather than 
a sagacious observer, seems to have made it an object of his treatise 
upon the French disease, published in 1551, to collect together all 
the errors of the writers upon syphilis of this period, and to add 
others of his own invention. Not only did he include all venereal 
affections under the head of syphilis, but, as described by him, this 
affection lost its characteristic physiognomy, and was a mere collec- 
tion of symptoms succeeding each other without order or regularity. 



INTRODUCTION. 29 

According to this author, buboes may appear before chancres upon 
the penis ; syphilis may commence indifferently as an exostosis, an 
eruption upon the skin, pains in the bones, or falling out of the hair 
and teeth. He goes so far as to admit eight primary symptoms, 
which he calls the simple forms of the disease, and which by their 
union in various ways may give rise to an infinite variety of com- 
binations, which he terms the compound forms of syphilis, and 
limits to two hundred and thirty-four in number. 

" Brassavolus, it is true, did not escape severe criticism. Gabriel 
Fallopius, his pupil, called his views ' futile inventions,' and Joseph 
Scaliger did not hesitate to say that Brassavolus was the echo of 
the vulgar herd of physicians of his day : ' Cymbalum ineptae 
medicorum plebis.' But error, especially when sanctioned by a 
great name, is a source of great danger, since many minds are wont 
to accept the opinions of others without criticism, and to study 
books rather than nature. The doctrines of Brassavolus, therefore, 
were not without influence ; and if we except the excellent treatises 
of Fernel and Leonard Botal, most of the works upon syphilis that 
appeared during the two following centuries, were more or less 
tainted with these doctrines. Even at the present day, since the 
publication of the writings of Hunter, and his annotators, we have 
still a school of Brassavolus. To be convinced of this fact, it is 
only necessary to read what has been published on syphilis since 
the commencement of the nineteenth century. 

"Yet, after the time of Brassavolus, the syphilitic ulcer, on 
account of the induration of its base, was still considered by some 
writers as distinct from the ulcer which is not succeeded by general 
symptoms. Thus Fallopius (A. D. 1555) devotes the eighty-first 
chapter of his treatise upon the French disease to the purpose of 
showing that there are several species of venereal sores ; that there 
is a great difference between the ' caries gallica ' and the ' caries non 
gallica ; ' that the former precedes the French disease, and has no 
connection with the latter, which is described in the writings of 
ancient and also in those of modern physicians prior to the year 1495. 

"After Fallopius, Antonius Fracantianus (1564), a celebrated pro- 
fessor at Bologna, also says that the sore which precedes general 
syphilis, may always be distinguished with ease from the one the 
action of which is local. 'Siquis carie afnciatur norunt non tantum 
chirurgi, sed et inepti tonsores, num caries ilia gallica sit nee ne ; 
hoc vero non nisi ab exustione et sorditie, quae livido vel nigro 
colore, et ex callositate innotescit.' 

"Again, Nicholas de Blegny, in 1673, speaks of the indurated 



30 INTRODUCTION. 

chancre; but, unlike preceding authors, does not regard it as a 
distinct species, but as an indication that the general symptoms of 
syphilis are likely to follow ; and, in this respect, his views agree 
with those of Eicord at the present day." [As the reader is probably 
aware, Eicord has since adopted the distinct nature of the two 
species of venereal ulcers.] 

"After the venereal affections which had been known in ancient 
times had thus been confounded with the disease which appeared 
at the close of the fifteenth century, and after the natural history 
of syphilis had been completely lost sight of under the supposition 
that the variations in the symptoms produced for the most part by 
treatment were really modifications in the course of the disease, an 
incident occurred which is worthy of attention, and does not require 
comment. Physicians perceived that the recent descriptions of 
syphilis did not coincide with those given by the authors who had 
witnessed the earliest appearance of the disease in Europe ; and as 
it was impossible to suspect that the earlier writers had omitted 
gonorrhoea and suppurating buboes, which were now regarded as 
the most frequent and positive indications of syphilis, they supposed 
that the type of the disease had changed, and that since its first 
appearance new symptoms had been added. Thus Brassavolus 
says that gonorrhoea was not a symptom of the French disease until 
about 1520 ; and Gabriel Fallopius, writing in 1555, that the same 
disease appeared fifteen years before as a new symptom of syphilis, 
the Protean nature of which is thus apparent. ' Ultimum signum 
est gonorrhoea gallica, signum incipientis morbi quas nobis indicat 
istius Protaei naturam.' Yet Alexander Benedictus had written 
more than fifty years before, that gonorrhoea, which had been 
known in every age, had become as it were epidemic since the 
appearance of the French disease ; still, the assertion of Brassavolus 
and Fallopius prevailed, and, repeated by most succeeding writers 
on syphilis, became, so to speak, a classic dogma. 

" Buboes were also considered of more recent date than the other 
symptoms of syphilis, and their origin was referred to the year 1514, 
because at that time they were first included among the manifesta- 
tions of the French disease by Nicholas Massa. 

" These pretended changes in the disease were the foundation of 
the fabulous 'periods' or 'epochs' of syphilis, invented by Astruc 
(A. D. 1736), and composed of various elements, among which are 
found : 1. The symptoms of those venereal affections which existed 
prior to syphilis and were successively annexed to it ; 2. Certain 
symptoms belonging to syphilis, as the late form of alopecia and 



INTRODUCTION. 31 

exostoses, which generally appear several years after infection, and 
which consequently did not figure in the early descriptions of the 
French disease which were written before the close of the fifteenth 
century; 3. Certain symptoms, as pustular eruptions, which were 
very prominent on account of their frequency and intensity for some 
years, "but which were afterwards supplanted in a measure by other 
manifestations of the disease which at an early period were quite 
uncommon, but which subsequently acquired a great degree of im- 
portance ; I refer to gummy tumors, which, according to Fracastorius, 
were very frequent about the year 1540. 

"In all these 'periods' of Astruc, only one fact is supported by 
medical tradition, and that is the gradual diminution in the intensity 
of syphilitic symptoms, which is attested by many reliable authors, 
and which is evident to any one who compares the frightful descrip- 
tions of this disease which were written in the latter part of the 
fifteenth century, with those which appeared twenty years later, or 
with others which have been published in our own day. 

" The modifications of the doctrines professed by those who wit- 
nessed the first appearance of syphilis in Europe, could not fail to 
affect the treatment of venereal diseases. Before the year 1495, 
ulcers of tne genital organs, the suppurating buboes dependent upon 
them, the various forms of vegetations and discharges from the 
urethra, were considered as purely local affections, and treated by 
means of local remedies. As soon as the French disease appeared, 
the insufficiency of all topical applications in the treatment of the 
new disease was manifest ; but human ingenuity^ never more fertile 
in resources than under circumstances of great necessity, soon dis- 
covered in mercury a powerful modifier of the new complaint. For 
several years this remedy was employed in the form of frictions,' 
and only in case the patient had broken out with an eruption fol- 
lowing a sore upon the genital organs; but it soon became the 
custom to resort to mercurial inunction immediately after contagion 
and during the existence of the primary sore, with a view of pre- 
venting the appearance of general symptoms. This practice was 
first recommended by James Cataneus, who thought that the same 
remedy which cured the pustular eruption would also prevent it. 
1 Hsec enim onctio, absque dubio^tale destruit virus quod enim unam 
sanat segritudinem, ab eMem prseservat.' 

" This wise precept, to employ mercurial medication during the 
existence of the primary sore for the purpose of preventing a gene- 
ral eruption, soon gave rise to the most serious errors; for, about 
the time that it was given, physicians began to ignore the di stinctioD 



32 INTRODUCTION. 

between the two species of ulcers, and were consequently led to 
treat them all indiscriminately with mercury. This injurious, not 
to say barbarous practice, has been continued to the present day, 
and has led to an exaggerated estimate of the powers of mercury, 
which, for three centuries, has been given to a multitude of patients, 
who have been supposed to be preserved through its influence from 
symptoms of which they stood in no danger. 

" Hence we may explain the success of all those modes of treat- 
ment which charlatans have endeavored to substitute for mercury 
when given during the existence of supposed primary symptoms, 
as a prophylactic against secondary manifestations; since, if the 
same treatment, no matter what, be applied without distinction to 
patients with gonorrhoea, ulcerations, and buboes, there will always 
be a large proportion who will escape farther trouble, for the simple 
reason that their symptoms do not belong to the disease which first 
appeared in the fifteenth century, and are, therefore, incapable of 
infecting the general system." 

Probably no cause contributed more po*werfully to the production 
and continuance during three centuries of confused ideas respecting 
venereal diseases than the fact that they are usually transmitted in 
the same manner, viz., by sexual intercourse. As already seen, 
this was a strong argument with George Vella in favor of their 
dependence upon one and the same poison; and it may well be 
doubted if it has entirely lost its weight at the present time. And 
yet it requires but a moment's thought to be convinced that this is 
the shallowest possible foundation upon which to build a theory as 
to the nature of any disease ; for if identity in the mode of commu- 
nication proves identity of species, we must regard all those affec- 
tions which are conveyed through the medium of the air, or, in 
other words, the whole tribe of epidemics, as constituting one dis- 
ease ; those which are communicated by contact, as the itch, favus, 
etc., another ; and so on, making as many species as there are ways 
of transmission. 

As Eollet has ably shown, 1 the communication of gonorrhoea, the 
chancroid, and the initial lesion of syphilis in the sexual act is 
merely .an accidental circumstance, and due to the fact that these 
diseases are capable of affecting the genital organs which are 
brought into such frequent and intimate contact. The conditions 

1 De la Plurality des Maladies Ve'ne'riennes, Gaz. Me*d. de Lyon, No. 7, Apr. 1, 1860. 
It is probable after all that the yaws and radzyge, as well as a number %f other 
contagious diseases hitherto supposed to be peculiar to certain localities, are nothing 
but syphilis. See Rollet, Recherches sur la Syphilis, etc., Paris, 1861. 



INTRODUCTION. 33 

during coitus are in the highest degree favorable for contagion to 
take place ; and all contagious diseases, the active principle of which 
is fixed and not volatile, which find their natural habitat in man, 
and which are capable of affecting the genital organs in the two 
sexes, are frequently transmitted in this manner. The only diseases 
of this latitude which fulfil these requirements are gonorrhoea, the 
chancroid, and syphilis ; while " in those countries in which other 
contagious affections, as the yaws and radzyge, foreign to our own 
climate, exist, they also are communicated in sexual intercourse, and 
are, strictly speaking, venereal." Scarlet fever, variola, measles, and 
other contagious diseases dependent upon a volatile poison, are 
naturally transmitted by way of the respiratory organs. Hydro- 
phobia, glanders, vaccinia, etc., are not natural to man ; and those 
contagious diseases which depend upon the presence of a parasite, 
as the itch, favus, and herpes tonsurans, are incapable of affecting 
mucous surfaces. 

This is not the only mode of transmission of veneral diseases, 
since gonorrhceal inflammation is not unfrequently communicated 
from one eye to another through the medium of the conjunctival 
discharge conveyed upon towels and other articles in common use ; 
and the secretion of the chancroid and of the lesions of true syphilis, 
whether primary or secondary, is contagious when properly applied, 
by whatever means, to any part of the body. In infants, the frequent 
and intimate contact of nursing takes the place of that during coitus, 
and the most common mode of transmission of venereal diseases is 
through the medium of the breast ; while even in adults syphilis is 
not unfrequently contracted from a primary or secondary lesion 
situated upon the mucous membrane of the mouth, tongue, or fauces 

GONORRHOEA AND SYPHILIS DISTINCT. 

Our review of the history of venereal diseases has incidentally 
furnished us with proof that gonorrhoea and syphilis are not 
dependent upon the same poison by showing that they have origi- 
nated at different periods, the former being known in all ages, the 
latter only since the close of the fifteenth century ; but the- chief 
evidence of the distinct nature of these affections, like that of all 
other diseases, is to be found in clinical observation. We infer that 
intermittent fever is different from whooping-cough,, the smallpox 
from rheumatism, phthisis from the measles, etc., because the symp- 
toms, course, termination and susceptibility to the action of remedies, 
in each, are different. And yet, in none of the diseases mentioned, 
is the difference greater than between gonorrhoea. and syphilis; thtf 

3 



34 INTRODUCTION. 

former being characterized by the symptoms of catarrhal inflamma 
tion common to mucous membranes, not infecting the general sys- 
tem, exposed to complications which are for the most part seated in 
organs which hold direct communication with the urethra through 
the medium of a mucous surface — as, for instance, the testicle, 
bladder and prostate, amenable to local treatment, and terminating 
in resolution and a complete restoration to health ; the latter disease 
commencing with an ulcer followed by a long category of general 
symptoms, its complications usually seated in the lymphatic system, 
mercury and iodine its chief remedies, its effect upon the constitu- 
tion, if not permanent, at least of long duration. 

And let it not be objected to this argument, that the premises 
assume what it is attempted to prove. Nothing has been assumed, 
but a simple statement given of the results of clinical observation. 
The differences which I have mentioned characterize the two dis- 
eases in the great majority of cases, as every one will admit ; and 
the general testimony afforded by the symptoms, course, and termi- 
nation is, in all diseases, considered sufficient to establish their 
distinctive character. In the exceptional cases, in which one dis- 
ease appears to run into another, we seek and are generally able to 
find an adequate explanation, although in some instances we fail ; 
but we do not, therefore, infer that the line of demarcation between 
them should be entirely effaced. 

Let any one follow out a series of cases of gonorrhoea from their 
commencement, assuring himself that the constitution is not already 
infected with syphilis from previous exposure, making a careful 
examination for the purpose of ascertaining that no chancre is 
present upon any part of the body, and keeping the patient under 
observation, in order to be sure that no primary sore is subsequently 
contracted, and it may safely be asserted that the investigation will 
satisfy any candid mind of the distinct nature of gonorrhoea. In 
all the reported cases, with scarcely an exception, which have ap- 
peared to favor a belief in the identity of gonorrhoea and syphilis, 
the mode of investigation has been exactly the reverse of the above. 
The patient has not been seen by the surgeon until general symp- 
toms have appeared, and the only knowledge of his previous history 
has been derived from his own lips. Now, such cases are entirely 
valueless, for the simple reason that a patient is an incompetent 
witness upon a subject with regard to which, unless a medical man, 
he is necessarily ignorant. He may state, with perfect honesty, that 
his only previous symptom has been an attack of gonorrhoea, and 
yet he may, without knowing it, have had a chancre within the 



INTRODUCTION. 35 

urethra, or«even upon the external surface of the genitals (since the 
superficial form which a chancre most frequently assumes, may be 
attended by such slight symptoms as entirely to escape observation), 
or a primary sore may have been situated upon some remote part 
of the body, and, consequently, its character not have been suspected, 
and, in many instances, careful inquiry and examination will show 
that one of these suppositions is true. There are also other sources 
of error too numerous to dilate upon here, but which will receive 
due consideration hereafter. Now, with these facts before us, and 
even granting, in some cases of general syphilis, apparently com- 
mencing with a discharge from the urethra without appreciable 
ulceration, that no plausible explanation can be discovered, which is 
the more probable; that such explanation really exists, or that 
nature in disease belies herself by contradicting in a few rare 
instances what she is constantly teaching in unmistakable terms in 
the overwhelming majority? 

Eicord thought to find additional proof of the distinct nature of 
gonorrhoea and syphilis in artificial inoculation. He inoculated the 
discharge of the former upon the patient and the result was nega- 
tive; the same experiment, performed, as he supposed, with the 
secretion of a chancre, was successful; whence he concluded that 
artificial inoculation upon the person affected, would enable us to 
distinguish between the urethral discharge of gonorrhoea and that 
from a concealed chancre. He has since discovered that a true 
chancre is not auto-inoculable, and, consequently, that his successful 
inoculations upon the individuals from whom the matter was taken 
must have been performed with the virus of the chancroid. It fol- 
lows, therefore, in respect to capability of inoculation upon the 
patient himself, that a chancre is precisely upon the same footing as 
gonorrhoea ; neither one nor the other is auto-inoculable ; and hence 
this test, at one time much insisted upon by Eicord, though not 
original with him, is proved fallacious. 

For all practical purposes, the idea that gonorrhoea is identical 
with syphilis is exploded ; for although, in some works upon vene- 
real, this error still retains the form and proportions which it 
assumed for three centuries, it is a corpse without life ; since, how- 
ever its friends may preach, it would be difficult to find one among 
them who puts his principles in practice, and treats gonorrhoea with 
mercury. Diday l has adduced the testimony of three of the Internes 
of the Hospital du Midi in proof of the fact that Yidal, one of the 

1 Nouvelles Doctrines sur la Syphilis, p. 100. 



36 INTRODUCTION. 

strongest advocates among recent writers of the syphilitic nature of 
gonorrhoea, invariably treated this disease as a simple inflammation 
without mercury. 

THE CHANCROID AND SYPHILIS DISTINCT. 

The separation of gonorrhoea from syphilis had for many years 
been received as beyond dispute, while the contagious ulcer of the 
genitals and that constitutional disease which was first known in 
Europe about the year 1494, were still confounded under the name 
of syphilis and regarded as modifications of one and the same affec- 
tion. In 1852, however, the discovery was announced that the 
latter diseases are as radically distinct as the former, and that they 
bear no resemblance to each other except in their most frequent 
mode of transmission by sexual intercourse. The great revolution 
in medical belief upon this subject which, in the few years that have 
since elapsed, has been constantly gaining adherents, and which even 
now, I do not hesitate to say, is supported by the greater weight of 
authority throughout the world, requires more than a passing notice. 
We may first, however, with both interest and profit, recall some of 
the glimmerings of this truth which had already crossed the minds 
of certain careful observers. 

It had for a long period been a matter of common observation 
that some venereal ulcers, even when not subjected to treatment, 
were limited in their action to the part upon which they were situ- 
ated and its immediate neighborhood ; while others were attended 
by infection of the general system. Mr. A., for instance, would have 
a sore upon the penis and a suppurating bubo in the groin, but, 
after these were healed, no further trouble ; while Mr. B. would 
contract an ulcer, which would be followed by a train of general 
symptoms, extending over a period of years, and perhaps affecting 
his offspring. This remarkable difference was explained on the 
ground of a diversity in the constitutions of the two individuals. 
The seed was supposed to be the same in both cases, but some pecu- 
liarity of soil in which it was implanted produced a different mode 
of germination. There was an unknown something in the system 
of Mr. A. which protected him from constitutional infection, while 
the absence of the same in Mr. B. exposed him to it. If either of 
these men should communicate his disease to a woman, her sore, it 
was thought, would be attended by systemic syphilis or not, 
according to her peculiar idiosyncrasy, and independently of the 
source from which the virus came. 

The unsatisfactory nature of these views had attracted attention 



INTRODUCTION. 37 

and awakened doubts of their correctness in the minds of several 
surgeons. Hunter devotes Part VII. of his work on Venereal to 
a consideration of "Diseases resembling the Lues Venerea, which 
have been mistaken for it," and which he is often evidently at a loss 
to classify. But although frequent misgivings as to the correctness 
of his views are to be found in his writings, he still maintained that 
"there is no difference in the kind of matter, and no variation can 
arise in the disease from the matters being of different degrees of 
strength ; the variations of the symptoms in different persons de- 
pend upon the constitution and habit of the patient at the time." l 
Abernethy was also at a loss to account for many syphilitic phe- 
nomena, and especially for the development or non-development of 
general syphilis after venereal ulcers which closely resemble each 
other. In his work entitled " Surgical Diseases resembling Syphilis," 
when speaking of venereal ulcers, he says : " It is from their effects 
upon the constitution alone that we can judge whether they are 
syphilitic or not." (p. 59.) 

Carmichael, 2 in 1814, took a decided stand in favor of a plurality 
of poisons, of which he admitted four, but he believed that they 
were all capable of affecting the constitution, though some were 
susceptible of spontaneous cure without mercury. The distinctions 
which he drew were grounded more upon the character of the erup- 
tion than upon the appearances of the ulcer, as will appear from the 
following summary : — 

" 1. The scaly eruption which appears under the form of lepra 
and psoriasis, and terminates in ulceration, is alone produced by the 
syphilitic primary ulcer, characterized by its slow progress, and its 
indurated edge and base ; and we find that both local and constitu- 
tional symptoms yield with almost invariable certainty and celerity 
to the action of mercury. 

" 2. The papular eruption which terminates in exfoliation of the 
cuticle may either be occasioned by the smooth superficial ulcer, 
without induration or ulcerated edges, or by a purulent discharge 
from the surface of the glans and prepuce (balanitis) ; or, thirdly 
by a gonorrhoea virulenta ; and we have found that these different 
species of the same disease are alike capable of a spontaneous cure, 
or of being removed by external astringent applications ; and that 
the constitutional disease they produce, is, like the primary, also 
capable of a spontaneous cure, which is promoted by antimony and 
decoctions of the woods. 

1 Ricord and Hunter on Venereal, 2d edition, p. 47. 

2 Essay on the Venereal Diseases which have been confounded with Syphilis. 



38 INTRODUCTION. 

" 3. The pustular eruption which terminates in ulcers, covered by 
crusts, is either occasioned by the phagedenic or sloughing ulcers. 
These distinctive venereal complaints, in their primary stage, are 
best treated by such means as subdue inflammation and sympto- 
matic fever, and by anodyne medicines, such as cicuta and opium. 
In their secondary stages, the decoctions of the woods, antimony, 
and mercurial salts, in alterative doses, are the means most to be 
depended upon ; but change of air, and such measures as may tend 
to strengthen the constitution, are also of unquestionable moment. 

" 4. The tubercular eruption which terminates in deep, irregular 
ulcers, has been traced, in one instance only, to a primary sore, which 
from the manner it undermines the skin, has been named the bur- 
rowing ulcer. But until other cases concur to demonstrate this 
connection, it would be premature to conclude that the one always 
occasions the other. The treatment is the same as for the phage- 
denic ulcer. 

"5. The diseases likely to be confounded with syphilis, which 
arise spontaneously from a disordered state of the constitution, fre- 
quently assume the form of the tubercular eruption. But after 
ulceration, the sores do not continue so extensive, jagged, and 
obstinate, and particularly under the means recommended, as those 
of venereal origin. Treatment : nitrous acid, the woods, and altera- 
tive doses of mercury." 

These views were never generally adopted, even in Dublin, where 
Carmichael resided, and after a brief notoriety were almost entirely 
forgotten. 

But Eicord appears to have had the clearest anticipations of the 
discovery which was destined to emanate from his " school," or from 
among his pupils and followers. In the absence of proof to the con- 
trary, this surgeon advocated, in general, the unity of the syphilitic 
virus, and explained its different effects on the ground of constitu 
tional differences already referred to ; but Mr. Victor de Meric 1 states 
that Eicord remarked to him many years ago: "You may rest 
assured that some day distinct origins will be found for the infecting 
and non-infecting chancres ;" and in the first edition of his Letters 
on Syphilis, published in 1851 (p. 257), when referring to the fact 
that in experiments upon syphilization, inoculation of the matter of 
chancroids had always produced chancroids, while in the sino-le 
instance that pus from a true chancre had been employed, a true 
chancre was the result, this author says: "If these results were 

1 Lettsomian Lectures, 1858, p. 9. 



INTRODUCTION. 39 

constantly obtained, we should be forced to conclude, that there are 
differences in syphilis which do not depend alone upon the condition 
of the individual upon whom the cause acts, but upon differences in 
the cause itself." 

With this brief history of opinion regarding this important ques- 
tion, we come down to the year 1852, when the first successful assault- 
was made on the old doctrine of idiosyncrasies and temperaments, 
and led to its final overthrow and the establishment of the duality 
of the chancrous virus. At this time, M. Bassereau, a former pupil 
of Kicord, published his " Traite des Affections de la Peau, Sympto- 
matiques de la Syphilis," a work characterized throughout by such 
originality of thought and accuracy of investigation that its perusal 
is essential to every one who would be thoroughly informed on 
venereal diseases. Although nominally a treatise upon syphilitic 
eruptions alone, many other subjects connected with syphilis are 
discussed, and among them the unity or duality of the virus, 
hitherto regarded as one. Justice to the author, the intrinsic and 
historical interest of his remarks, the manly and cogent style of his 
reasoning, and the absence, so far as I am aware, in the English 
language, of any suitable exposition of his views expressed at this 
early day, demand a somewhat extended quotation, which I shall 
give in the form of a free translation, with such abridgment as my 
limits as to space require. 

It is necessary to premise that this question is discussed by 
M. Bassereau in his chapter on syphilitic erythema, which, being 
one of the earliest symptoms of general syphilis, affords a better 
opportunity for tracing the connection between primary and 
secondary lesions than any other. The cases of erythema, to which 
frequent reference is made, number 170, if we exclude twenty-eight 
in which the absence of information regarding the primary ulcer 
precluded any comparison. 

In the tenth section of the chapter upon this subject, entitled: 
" Eecherche des causes qui ont pu determiner le developpement de 
l'erytheme, c'est-a-dire la generalization des symptomes syphilitiques 
dans l'economie," M. Bassereau says : — 

"There can be no question of the fact that there are venereal 
ulcers which may be treated by the most simple remedies without 
the employment of any mercury whatsoever, and yet never be 
followed by the symptoms of general syphilis. Any one may 
convince himself of this truth by inquiring of old men, many of 
whom will state that they had venereal ulcers several times in their 
youth, which were treated with simple cerate, lint, or other rceans 



40 INTRODUCTIOX. 

destitute of specific action, and, though they have never taken 
mercurials, there has not been the slightest appearance of constitu- 
tional syphilis during the thirty or forty years which have since 
elapsed. Many persons also will repeatedly have ulcers and escape 
infection, but will finally contract another which will be followed 
by a syphilitic eruption. Why this difference ? What should limit 
the action of the sore in the one case and in the other extend it to 
the whole system? This is an interesting problem, and I will 
proceed to give the results of my attempts to solve it. Let no one 
who is wont to pay respect to opinions which have received the 
stamp of authority take umbrage at the novelty of the propositions 
which I am about to present, or be hasty in rejecting them. The 
question at issue is so important that it deserves serious examination. 
It is not to be decided by an appeal to the vague impressions left 
on the mind by former experience, or by the doctrines of this school 
or that ; it can only be settled by new investigations undertaken for 
the very purpose. I ask therefore of unbiassed men to devote the 
necessary time to verify the facts which I am about to present, and 
to give them their most scrupulous attention. 

"Among the causes which I have investigated, I have endeavored 
to ascertain if age has any influence upon the infection of the 
system by syphilis, and I have satisfied myself that it has none. 
From birth to the most advanced years, men may have sores which, 
at any age, may be followed by general syphilis ; and though infec- 
tion is more common among the young, it is simply because they 
are more exposed. Sex is equally devoid of influence. Ricord 
states that venereal ulcers are less frequently indurated in women 
than in men, which is equivalent to saying that women are less 
liable to syphilis, since it can be easily shown that infection attends 
in most cases indurated chancres. I do not believe, however, that 
Eicord carries the induction thus far. For my own part, I think 
that the rarity of induration in women is only apparent. Indeed 
in an examination of the same number of venereal ulcers in the 
two sexes, I have found nearly the same proportion indurated in 
the one as in the other ; with this difference, that the induration was 
generally poorly marked on the vulva, while it was very decided 
upon the penis. Just as the skin of various parts of the body is 
not equally susceptible of the development of induration, so this 
symptom is less frequent upon the genital organs in women than 
in men. But women are not on this account less exposed to syphilis. 
Though fewer persons of this sex are affected with this disease it is 
because the number who are addicted to debauch is incomparably 



INTRODUCTION. 41 

less than of men ; whence venereal affections of all kinds, syphilis 
included, are less common among them, and the difference cannot be 
attributed merely to sex. 

"Again, idiosyncrasy will not explain the fact that a sore is only 
local in its effect in one person, while in another the system at large 
is contaminated. This is proved by the number of persons who, 
after having numerous simple ulcers, contract another which becomes 
indurated and is followed by general manifestations. 

" Can such different results from two acts of contagion by a virus 
reputed the same be accounted for by the changes which frequently 
take place in the constitution, and by virtue of which a man is not 
affected in the same manner by the same agent at times very nearly 
approximated? Doubtless such dissimilar effects might depend 
upon the particular disposition existing at the time of contagion ; 
but this explanation is admissible only in default of a better, espe- 
cially as it is opposed to what we know of the action of specific 
causes, which always tend to produce the same results. 

"I have carefully studied the temperament and constitution of 
persons affected with syphilitic erythema, in order to discover if 
any one of these organic modifications of the system might not 
influence the development of syphilis, but such inquiry has led to 
no positive result. I have found all temperaments affected in nearly 
equal proportion ; none can therefore be regarded as peculiarly con- 
ducive to the extension of the virus throughout the economy ; and 
the same may be said of difference of constitution. 

" An insufficient amount or the bad quality of food, which is a 
powerful aggravating cause of syphilitic symptoms, has been so 
rarely observed in the cases of erythema which have come under 
my notice, that it is impossible to ascribe to it the development of 
general syphilis. The abuse of alcoholic stimulants, changes of 
temperature, and intercurrent diseases appear to have had no more 
effect. I have merely noticed that chancres contracted during warm 
weather are more rapidly followed by syphilis than during cold. 

" The above remarks clearly show that neither age, sex, idiosyn- 
crasy, temperament, constitution, hygienic influences, nor coexisting 
diseases which might be supposed to have depressed the system at 
the time contagion took place, can, each by itself, be regarded as the 
determining cause of infection; and if we group them all together 
instead of considering each singly, my statistics will show that they 
will not account for one-third of the cases of constitutional disease. 
The better to appreciate the etiological value of these influences, I 
have examined the condition of those persons whose ulcers, in spite 



42 INTRODUCTION. 

of the absence of all treatment capable of retarding or destroying 
a tendency to secondary symptoms, have not been followed by gene- 
ral syphilis. I have compared one hundred such cases with an 
equal number of patients affected with syphilitic erythema, and 
have found in each nearly the same proportion of lymphatic tem- 
peraments, feeble constitutions, bad hygienic influences, etc., thus 
confirming my opinion of the necessity of searching for other than 
physiological and hygienic causes of the generalization of syphilitic 
manifestations. 

" I have also sought for the solution of this question in the sore 
itself. I have endeavored to ascertain if repeated acts of contagion 
might not favor the appearance of secondary symptoms. On exam- 
ination of the cases cited, I found that in 112 cases the eruption 
appeared after several successive ulcerations, and in 86 after a single 
one. Notwithstanding the predominance of the former, it cannot, I 
think, be admitted that repeated attacks are the cause of constitu- 
tional infection. The idea that the action of a virus must be accu- 
mulated to produce its utmost effect is but little in accordance with 
the medical knowledge we already possess. In a number of my 
cases, also, there was so long an interval between the ulcers that it 
appears to me difficult to attribute to the first contagion any influ- 
ence whatever in the production of the syphilitic manifestations 
which followed the last exposure. 

"Again, I have inquired if individuals affected with several 
ulcers at one time, were not more exposed to constitutional infec- 
tion than those having only one, and who consequently bore upon 
their persons a smaller surface secreting contagious matter ; but I 
found this could not be the case, for of the 170 instances of syphi- 
litic erythema, 141 had had but one, and only 29 multiple ulcers ; 
whence I conclude that neither the plurality of the sores nor the 
extent of the secreting surface can be regarded as the cause of the 
constitutional manifestations which sometimes appear. These results 
are analogous to those obtained by Kirkpatrick, Dimsdale, and 
Gatti in experiments with the virus of variola, from which it ap 
pears that there is no connection between the number of inoculated 
points and the copiousness of the consecutive eruption. Girot even 
observed that the eruption of variola was milder and more discrete 
after inoculating in six places than when only two punctures were 
made. 

"An analysis of these cases of syphilitic erythema also shows 
that tne development of general syphilis is not affected by the situa- 



INTRODUCTION. 43 

tion, 1 degree of ulceration, or duration of the sores. General symp- 
toms may supervene, on whatever part of the body the sore is 
situated ; and the intensity of the former is not increased when the 
ulcer is at a distance from the genital organs, as was once supposed 
by Boerhaave. A decided tendency to extend by ulceration is also 
innocent of the development of constitutional syphilis ; for I have 
often seen the mildest and most superficial erosions followed by 
infection, while phagedenic sores proved innocuous. Those ulcers 
which last for a long period are not more likely to terminate in 
secondary syphilis than those which cicatrize within a moderate or 
short space of time, as may also be seen from an examination of 
these 170 cases. 

" On the other hand, induration is so frequent a symptom of these 
ulcers 2 that it is impossible not to admit that it bears an intimate 
relation to the syphilitic erythema which ensued. But even if it 
could be shown that all chancres are indurated, must we necessarily 
say that induration is the cause of infection ? By no means ; for 
this would only be avoiding the question instead of solving it, since 
the cause of the induration would still remain to be discovered. 

"Finally, in my investigations I have endeavored to ascertain if 
any relation existed between the symptoms presented by my patients 
and those of the persons from whom they contracted their disease. 
Such inquiry is often difficult, for men are frequently infected by 
women whom they never see but once, and of whose name and 
address they are ignorant. Some have intercourse with several 
women within a short time preceding the appearance of the sore, 
so that the source of the virus is doubtful ; others refuse to give 
any information with regard to the persons with whom they have 
had connection. In some cases, however, we are able to compare 
the symptoms in the two sexes. Patients often bring to me for 
examination the women who infected them, or else put me in the 
way of visiting them at their homes. Frequently, also, at the 
Hopital des Yeneriens, I have found two or three, or even a larger 
number of men who contracted their disease from the same woman, 
either on the same day or at a few days' interval. Finally, in several 
instances I have seen both a wife and a husband, and even their 
children, all affected with syphilis which had been introduced into 
the family through one of its members. 

1 At the time this was written, the fact that chancroids are rarely met with upon 
the head or face was not known. 

2 Of the 170 chancres, 157 were known to be indurated; in 13 induration was 
doubtful. 



44 INTRODUCTION. 

" These repeated confrontations of persons infected by each other 

— undertaken at first to determine what syphilitic lesions are con- 
tagious and what are not; to show what symptoms may succeed 
others, and what modifications the same symptom may undergo by 
transmission between individuals of different sex and temperament 

— have led to the discovery of that hitherto mysterious cause by 
virtue of which venereal ulcers sometimes limit their action to the 
part on which they are situated and the neighboring ganglia, and at 
other times extend their effect to the system at large and are followed 
by general syphilis. The following propositions embody the results 
obtained from the confrontation of patients affected not only with 
erythema, but also with other syphilitic eruptions and primary sores, 
with those persons from whom their disease was derived : — 

" If we compare persons who have had venereal ulcers followed 
by general symptoms with those persons who inoculated them, or 
with those whom they in turn have inoculated, we find that all, 
without exception, have had constitutional syphilis ; never, in any 
case, has the action of the sore been merely local. 

" On the other hand, by the comparison of individuals who have 
had ulcerations which did not result in general manifestations with 
the individuals who infected them, or with those whom they have 
infected, we find without exception that the latter, equally with the 
former, have had sores, the action of which was limited to the part 
first inoculated. Thus an ulcer followed by constitutional syphilis 
never gives rise to a merely local ulcer ; and a purely local ulcer 
cannot produce an ulcer which will be followed by the general 
manifestations of syphilis. The uniformity of the facts which have 
come under my observation — none but apparent exceptions having 
ever been met with — fully justifies me in enunciating the following 
proposition as a law: — 

" Whenever a "person has a chancre and afterwards general syphilis, 
the generalization of the disease is first of all due to the fact that the 
person from whom the contagion cam£ had a chancre which was neces- 
sarily followed by general symptoms. 

"Of thirty-four cases of syphilitic erythema, in which I have 
been able to confront the patients with those who infected them, 
and in some instances with those whom they had afterwards infected, 
in thirty-one, conformably to the law just enunciated, all the indi- 
viduals thus confronted presented lesions of the same character; 
all without exception had ulcers which were followed by general 
syphilis. In only three, from the absence of symptoms of general 
infection, did there seem to be any exception, but induration was 



INTRODUCTION. 45 

found at the site of the sore, showing that the exception was only 
apparent ; moreover, the mercury which had been administered for 
the latter fully accounted for the absence, or delay in the appearance, 
of general manifestations." 

The immutability of these two varieties of venereal ulcers being 
thus established by clinical experience, it is evidently necessary to 
admit that they constitute two species. The question then remains 
whether or not they bear any relationship to each other. One of 
two alternatives must be true : the virus of both must be the same, 
but of greater intensity in one than in the other ; or there must be 
two poisons totally and radically distinct. 

Two years after the publication of M. Bassereau's work, the first 
mentioned supposition was adopted by M. Clerc, 1 another pupil of 
Eicord, who maintained that the virus of the soft was a modification 
of that of the hard variety ; the former bearing the same relation to 
the latter that varioloid does to variola, and the false to the true 
vaccine pustule ; and in accordance with this view, the name of 
"chancroid" was given to the first, while the term chancre was 
exclusively reserved for the second ulcer. This modification, as M. 
Clerc believed, was produced by the passage of the virus through 
the system of a person already under the influence of the syphilitic 
diathesis ; the poison, thus materially changed in its nature, was 
capable of indefinite transmission by contagion, but could never 
recover its original power of infecting the constitution ; just as the 
false vaccine pustule may sometimes 2 (not always) be inoculated 
from one individual to another without affording protection against 
variola, or, in other words, without exerting any influence upon the 
general system. 

M. Clerc's theory was sufficient to explain all the phenomena 
hitherto stated in the quotation from M. Bassereau, and it only 
remained to demonstrate by direct observation whether or not the 
transmission of the syphilitic virus through a system already infected 
would produce such modification as was claimed in its nature. At 
the time M. Clerc's essay appeared, the necessary facts were want- 
ing to determine this point, but they have since been met with and 

1 M6moire du Chancroi'de Syphilitique, Paris, 1854. 

2 The theory of M. Clerc appears to be as defective in its analogies as in the ab- 
sence of direct proof, for the false vaccine pustule is not always perpetuated as 
such ; and there is abundant evidence — cited very fully by M. Fournier (Legons sur 
le Chancre, p. 168) — to show that varioloid may give rise to variola and vice versa 
in subjects unprotected by vaccination or previous attacks. The assumed per- 
manence of these forms of disease, when once established, cannot therefore be 
sustained. 



46 INTRODUCTION. 

have proved the theory without foundation. In several instances, 
a man laboring under the symptoms or diathesis of general syphilis 
has contracted a sore from a woman having a true chancre, and 
although, under these circumstances, as will be seen hereafter, the 
ulcer in the male closely resembles a chancroid in appearance, yet 
if it be communicated to a third person as yet free from constitu- 
tional taint, the result will be a chancre and general syphilis. "We 
thus have positive proof that no such modification takes place as 
asserted by M. Clerc ; and his theory is at present generally aban- 
doned, although the term " chancroid" is conveniently retained to 
distinguish the local ulcer from the true chancre. 

Bassereau regarded the first alternative above mentioned, of which 
Clerc's theory is the only representative, as deserving of rejection 
from the absence of any proof in its favor ; and boldly advocated 
the second, viz., that the virus of the chancroid is radically distinct 
from that of a chancre. 

As we have already seen, Bassereau found additional evidence of 
the correctness of this view in a careful study of the older writers 
on medicine, irom which it appears that simple venereal ulcers have 
been known from the earliest times of which we have any record ; 
that the true chancre and general symptoms were first observed in 
the latter part of the fifteenth century, during the Italian epidemic ; 
and that for twenty or thirty years afterwards these two species of 
ulcer were never confounded ; the duality of the chancrous virus is 
not therefore a modern discovery, but was familiar to those who wit- 
nessed the first irruption of syphilis into Europe. 

Adopting Bassereau's own words: "When we read all that 
ancient and modern authors have written on the diseases of the 
organs of generation, we find that gonorrhoea, venereal ulcers, 
buboes, and vegetations are mentioned as late as the last years of 
the fifteenth century, as diseases requiring only local treatment ; up 
to this time there is not the slightest allusion to any symptoms 
consecutive to the diseases of the genital organs. The end of 
the fifteenth century, according to all contemporary authors, was 
marked by the appearance of a new disease. This disease com- 
menced by indurated ulcers upon the genital organs, which were 
speedily followed by pustular eruptions over the whole body, and 
by frightful pains in the head and limbs. The physicians who were 
eye-witnesses of the new disease did not at first confound the callous 
ulcers in which 'it commenced with the ulcers of the genital organs 
wlich had been known for ages. Thus these two species of ulcers 
occupy in their writings separate chapters, and even separate books. 



INTRODUCTION. 47 

But, twenty or thirty years after the appearance of syphilis in Eu- 
rope, many physicians not knowing, as those did who witnessed its 
first ravages, how to distinguish the symptoms by which the new 
disease commenced from those which had no relation whatever with 
it, assumed by degrees the habit of submitting to mercurial treat- 
ment, without distinction, all persons affected with gonorrhoea, ulcers 
and buboes ; for it had already become a general practice to admin- 
ister mercury, not only for the purpose of modifying existing syphi- 
litic symptoms, but also as a prophylactic agent against future 
symptoms, as soon as the first signs of contagion began to appear. 
The confusion which reigned in practice was soon introduced into 
the works of the day ; the writers on syphilis in the middle of the 
sixteenth century included, one by one, under the name of syphilis 
all those venereal symptoms which had been known from the earliest 
antiquity, and which the physicians who exercised their art in the 
last years of the fifteenth century had taken care to separate from 
the symptoms of the new disease." 

The attention of the profession being thus directed anew to the 
important question of the unity or duality of the chancrous virus, 
other observers immediately set to work to test the accuracy of M. 
Bassereau's observations, and new facts soon began to appear, all of 
which were found to point in the same direction. In 1856, M. 
Dron 1 was able to collect one hundred and eleven instances of con- 
frontation, including those of Bassereau relating to the initial lesion 
of syphilis, those of M. Clerc relating to the chancroid, and others 
relating to both varieties furnished by Diday, Kollet, Eodet, and 
Fournier, and in all, without exception, the type of the ulcer 
remained unchanged in passing from one individual to another. 
Farther investigations, under the supervision of Eicord and with 
the same result, were made by MM. Fournier and Caby, who availed 
themselves of the unequalled facilities for such examination afforded 
by the chief venereal hospitals of Paris — one (du Midi) devoted to 
men, the other (St. Lazare) to women — and of the vigilance of the 
French police. These observations were published in detail by M. 
Fournier in his edition of Eicord's Legons sur le Chancre, 2 and also 
in a pamphlet entitled, Recherches sur la Contagion du Chancre, 3 and 
comprise fifty-nine cases of transmission of chancres, and thirty-nine 
of chancroids. The value of many of these cases was materially 
enhanced by the fact that two or more men were contaminated by 
the same woman, and thus the testimony in favor of the duality of 

1 " Du Double Virus Syphilitique," these de Paris, 1856 

2 Paris, 1858. 3 p ar i s , 1857. 



48 INTRODUCTION. 

the chancrous virus was multiplied. In one, two friends, who 
shared the favors of the same woman having a true chancre, caught, 
each of them, a chancre followed by general symptoms; and the 
father of one of them, an old man aged seventy-three, had connec- 
tion with his son's mistress, and met with the same fate. Again, 
six persons were infected from the same source, and the consequences 
in all were identical, viz., chancres and general manifestations. So 
with the chancroid; in several of Fournier's cases, two, three, or 
four men, bearing chancroids, were found together in the wards of 
the Hopital du Midi, all of whom ascribed their contagion to the 
same woman ; who, on examination, was proved to have the same 
species of sore ; and in none did general symptoms appear during 
several months that they were kept under observation. 

Thus far in our account of Fournier's investigations, we find that 
they merely confirm the observations of Bassereau, since they all 
relate to the transmission of venereal sores between persons free 
from previous syphilitic taint. It remains to be proved what effect; 
if any, is produced in each species by being communicated to a 
system already under the influence of the syphilitic diathesis. The 
solution of this question was also undertaken by Fournier, who 
found, as regards the chancroid, that the sore was in no way modi- 
fied ; that if, for instance, a woman having a chancroid, communi- 
cated it to a man whose constitution was already infected with the 
virus of true syphilis, and he gave the same to a woman free from 
such taint, the resulting sore would in no respect be changed in 
consequence of the general infection of the man through whom it 
had been transmitted. This result might have been predicted before- 
hand, from a consideration of the distinct nature of the two kinds 
of virus, neither of which will directly influence the other, any more 
than syphilis will affect the course of gonorrhoea, or vice versa. 

With regard to the true chancre the results were more novel and 
interesting. A sore of this species, communicated to a subject 
already infected with syphilis, does not present its usual character- 
istics ; it is either not at all or only imperfectly indurated and is 
unaccompanied by induration of the neighboring lymphatic gan- 
glia ; in short, it so closely resembles a chancroid that it cannot be 
distinguished from it by any outward sign. 1 If, however, this sore 

in appearance a chancroid, but in reality a chancre, modified by 

the constitutional infection of the person bearing it — be communi- 
cated to a third person free from constitutional taint, it will resume 

1 This point will receive further consideration hereafter. 



INTRODUCTION. ' 49 

its normal characteristics, will become indurated, be accompanied 
by induration of the neighboring lymphatic ganglia, and be followed 
by the general manifestations of svphilis. 

The evidence on which the statement just made regarding a 
chancre is based, is sufficient, though not so great in amount as that 
relating to the transmission of chancres between individuals free 
from constitutional infection ; since facts capable of solving the 
question under consideration are necessarily rare. For, in the first 
place, the syphilitic virus rarely takes effect at all upon a subject 
already infected ; one general attack protecting against even local 
manifestations of the poison, just as vaccination is without result 
upon a system once imbued with the vaccine or variolous virus ; 
and, in the second place, supposing contagion to occur, the disease 
must be again communicated to a person who has always been free 
from constitutional taint. These numerous and complex require- 
ments, however, have all been present in seven cases, of which 
Cullerier, 1 Melchior Eobert, 2 and Diday, 3 each observed one, and 
Fournier and Caby four ; and they all concur in showing that, con- 
trary to M. Clerc's theory, the syphilitic virus is not modified by 
being communicated to a system already infected, and although it 
produces a sore apparently identical with a chancroid, its essential 
attributes are unchanged. 

Another point to which Fournier directed his attention was whe- 
ther phagedenic ulceration is due to any peculiarity inherent in the 
virus — a question which the confrontation of patients answers in the 
negative. The origin of phagedena is probably complex, being 
attributable in some cases to noxious principles in the primary pus 
of contagion, more frequently to constitutional cachexia in the reci- 
pient, and sometimes to both causes combined ; but without entering 
fully into its etiology, it is sufficient for our present purpose to say 
that the virus of phagedenic ulcers is not a distinct species, since 
this form of ulcer may owe its origin either to a chancroid or a true 
chancre. 

The results thus far attained by comparison of the symptoms of 
those giving and those receiving venereal ulcers may be summed up 
in the following propositions : — 

1. Among persons free from previous syphilitic taint, each of the 
two species of ulcer is transmitted in its kind: the chancroid as- & 
chancroid limited in its action to the neighborhood of its site ■; the 
chancre as a chancre, followed by general manifestations. 

1 Fournier, Contagion du Chancre, p. 57. 2 Dron, These, already referred to. 

3 Annuaire de la Syphilis, annee 1858, p. 277 

4 



50 INTRODUCTION. 

2. A sore with a soft base, and unaccompanied by induration of 
the neighboring lymphatic ganglia, in a subject already infected 
with syphilis, will, when communicated to a person free from syphi- 
litic taint, give rise either to a chancroid or to a chancre, according 
to the nature of the virus which occasioned the first mentioned 
ulcer. 

3. The virus of a chancroid is a poison distinct from that of a 
chancre. 

4. Phagedenic ulceration of a venereal ulcer does not depend 
upon a specific difference in the virus. 

In reviewing the labors, of which a somewhat full account has 
now been given, we find that the duality of the chancrous virus is 
established upon the same evidence as naturalists determine the 
identity of species in the animal and vegetable kingdoms ; viz., by 
the immutability of certain traits in successive generations. The 
" immutability of species" lies at the foundation of all classification 
in natural history ; it is the groundwork upon which the whole 
superstructure rests ; and although we cannot always expect to fol- 
low out the same laws in the arrangement of the Protean forms of 
disease that we do in nature, the simple principle referred to is 
unquestionably as applicable to one as to the other ; nay, when pre- 
sent in morbid manifestations, it may be regarded as of the greatei 
value from the very fact of their general inconstancy. The character- 
istics, the immutability of which is relied upon to establish the 
duality of the chancrous virus, are the limitation of the power of 
the ulcer to mere local action on the one hand, and, on the other, its 
necessary influence upon the general system ; and no one will fail to 
see that, if these can be proved to be constant, they are sufficient to 
establish a distinction of species. 

It should be observed that the external appearance of venereal 
ulcers does not enter as an element into this consideration. The 
proof would be equally valid, even if it could be shown that the 
two species are never distinguishable by any outward sign. It is 
sufficient to establish the fact that the action of the virus in one 
series of cases is local, and in the other general. Naturalists, in 
many instances, ground their classification of species upon differ- 
ences confined to one period of their existence. The young of many 
forms of animal life closely resemble each other, although the adults 
are widely different. From the study of embryology alone, Agassiz 
has derived the most correct system of classification which has ever 
beer advanced. While, therefore, as will hereafter appear, the 
chancroid arid chancre do present, in most cases, differences recoo-. 



INTRODUCTION. 51 

nizable by the sight and touch, these must be regarded as additional, 
but not essential, evidence of the distinct nature of the two diseases ; 
and their absence, as occurs in some instances, and perhaps in all, 
when the virus of a chancre is implanted upon a system already 
infected, does not invalidate the above reasoning. 

The new doctrine upon this subject, which, as shown by Bassereau, 
is an old doctrine revived, appears to me to occupy an impregnable 
position. The confrontations of the observers whose names have 
been mentioned, alone amount to 137, and among them all, not a 
single instance of interchange between the two forms of ulcer has 
been met with. Moreover, as Eollet remarks, this number is but a 
tithe of the concurrent testimony which we now possess on this 
point ; since, in addition to the confrontations of persons having 
venereal ulcers reported by the authors now cited, we may rightfully 
include the hundreds of recorded cases of the communication of 
syphilis from secondary lesions, either between nurses and infants 
or between adults ; the numerous instances in which the disease has 
been conveyed by vaccination ; those in which the syphilitic virus 
has been artificially and intentionally inoculated upon persons free 
from syphilitic taint; and the tens of thousands of inoculations 
(usually with the virus of the chancroid) employed in the so-called 
practice of syphilization : — in all of which either syphilis has been 
the origin of syphilis, or a local contagious ulcer the origin of a 
local contagious ulcer. Again, upon no other ground than a duality 
of poisons, can we satisfactorily explain why the same individual 
should repeatedly contract a local sore and after a short interval 
incur another contagion resulting in constitutional infection; or why 
a chancroid and a true chancre should ever coexist upon the same 
person — instances of which are of almost daily occurrence. Nearly 
every surgeon has the opportunity to satisfy himself of the truth 
of this doctrine by personal observation; let him but 'take note of 
the not unfrequent cases in which a husband gives a venereal ulcer 
to a wife whose fidelity cannot be called in question, and he will find 
that they will both escape, or both incur constitutional infection. 
Thus, every one can contribute his quota to the statistics on thii 
interesting subject. For myself, in a somewhat extended field oi 
observation during twelve years of practice, I have never seen an 
instance of interchange of the chancroid and syphilis. 

In pursuing these investigations, it is of course necessary to guard 
against all sources of error ; the fact should be well established that 
the person supposed is re»lly the one who gave the disease ; it should 
be ascertained with certainty that neither the man nor woman has 



52 INTRODUCTION". 

been previously infected, otherwise he or she is incapable of receiving 
a second infection ; and the influence of a mercurial course in pre- 
venting, or more frequently in retarding, general manifestations, 
should be borne in mind. Nor is mercury the only agent capable 
of delaying the appearance of secondary symptoms ; the same effect 
may be produced by a course of iodide of potassium, sudorifics, or 
other medicines which increase the excretions from the body. 

It is now evident that the local contagious ulcer of the genitals 
should no longer be described under the head of syphilis, but should 
be considered apart like gonorrhoea, as was done by writers upon 
Venereal during the thirty years immediately succeeding the Italian 
epidemic. 

With regard to the nomenclature of the contagious ulcer of the 
genitals and the initial lesion of syphilis, both of which until 
recently were included under the head of " chancres " or " primary 
syphilis," no little confusion at present exists. Their distinct nature 
being recognized, it is of course desirable to designate them by 
distinct names ; but, retaining the term chancre for one of them, to 
which shall it be applied, and how shall we call the other ? Most 
French and English writers have seen fit to follow the nomenclature 
adopted by Clerc, and call the former a " chancroid " and the latter 
a " chancre ; " instead of which Diday calls them " chancrelle " and 
"chancre," from the analogy of the terms varicella and variola; 
while the German school of to-day, represented by Hebra, Zeissl, 1 
Keder, 2 Lindwurm, 2 and Dr. Elsberg 4 among American authorities, 
apply the name of chancre exclusively to the local ulcer of the 
ancients, and designate the sore of 1494 by the term " initial lesion 
of syphilis," or "primary syphilis." 

1 Allgemeine Wiener Medizinische Zeitung, January 1862. A translation of a por- 
.tion of this article may be found in the Boston Medical and Surgical Journal, May 

15, 1862. Zeissl's clinique is made up of Hebra's venereal patients, and the views of 
the former surgeon are fully endorsed by the latter. 

2 Ueber die Trennung des Schankers von der Syphilis. Medizinische Jahrbiicher, 
Heft I., 1862. 

3 Ueber die Verschiedenheit der syphilitischen Krankheiten. 

* Dr. Elsberg claims to have been the first to propose this nomenclature of venereal 
ulcers. He Bays in a letter to the author : " I regret my inability to refer you at this 
time to any printed article in which I have proposed to limit the term chancre to the 
local venereal sore, and to call the corresponding initial lesion of syphilis at once by 
the latter name. The simplicity, logical correctness, and incidental advantages of 
sucn a nomenclature, first occurred to me during my visit to Europe in 1858, while 
privately discussing the general subject. I afterwards publicly stated and advocated 
it in *be Med. Soc. at Frankfort on the Main (by wh^om it. may have been published); 
again in a letter to Prof. v. B'arensprung ; before the Medico-Chirurgical College of 
this city in 1860 ; and again at great length in a discussion, Feb. 13, 1862." 



INTRODUCTION". 53 

Now, much may be said in favor of the German plan, which com- 
mends itself by its simplicity and its theoretical accuracy. Accord 
ing to it, one man contracts a venereal ulcer, local in its character 
and incapable of infecting the system, and we say he has a chancre ; 
another man contracts the other venereal sore and we say he has 
syphilis, thus expressing at once the idea that his system is just as 
much contaminated and that the same general treatment is required as 
if secondary manifestations had already made their appearance. To 
be sure he exhibits as yet only the "initial lesion of syphilis," but 
the mischief is already done ; the sore is not and never has been 
local ; it is not the disease itself, but the manifestation or symptom 
of a disease — which is syphilis. In like manner, when a person 
breaks out with a pustule succeeding vaccination, we do not say he 
has a pustule, but that he has vaccinia ; and why, it may well be 
asked, should not the name of the disease upon which the mani- 
festation depends, be used in the one case as well as in the other ? 

If, therefore, we could at will arrange our venereal nomenclature 
de novo, and forget the signification which has for centuries been 
attached to certain terms, I should not hesitate to adopt the plan 
referred to; but it appears to me that the idea of- syphilis in con- 
nection with " chancre" is too deeply rooted in the minds of profes- 
sional readers to render their disseverance practicable without 
introducing great confusion. Moreover, the German plan has this 
objection, that it gives one no single word to express "the initial 
lesion of syphilis," and the inconvenience of resorting to such circum- 
locution on all occasions will be appreciated, if the reader will notice 
how often the idea of this sore must be conveyed in the introduction 
alone of the present work. 

I believe, also, that the advantages attached to the German 
nomenclature can be attained in a simpler way ; indeed, that they 
are already well nigh attained, since it is now very generally under- 
stood among those conversant with modern views of venereal dis- 
eases, that when a man has a local venereal ulcer he has a " chan- 
croid" and not syphilis, and that when he has a "chancre" his 
system is already infected with the syphilitic poison, and that his 
disease is syphilis. To consummate the desired end, it is only 
necessary to abolish in toto the illogical terms " soft chancre," " hard 
chancre," " infecting chancre," etc., and to have it understood inai a 
" chancre" always means the initial lesion of syphilis and nothing 
else, and that its presence is due to infection of the constitution with 
the syphilitic virus. The nomenclature adopted in the present editiou 
of this work is in accordance with this view, and I shall designate 



54 ' • INTRODUCTION. 

the local contagious ulcer of the genitals as the chancroid, reserving 
the term " chancre" exclusively for the initial lesion of syphilis. 

The distinction which is now drawn between the chancroid and 
chancre explains in a great measure the variance which has long 
existed with regard to the treatment of venereal sores between the 
" mercurialists" and " anti-mercurialists." The former, being a 
strictly local disease, requires no constitutional remedies, unless, in 
exceptional cases, as adjuvants to local treatment. Mercury is only 
of value in cases of syphilis, including its initial lesion or chancre. 
Since the number of cases of chancroid met with in practice greatly 
exceeds those of chancre, it is evident that the general results of 
treatment may be made to sustain either the use or disuse of mer- 
cury, if exclusively applied to both affections in common. 

COMPARISON OF THE THREE POISONS OF GONORRHOEA, THE CHAN- 
CROID, AND SYPHILIS. 

A comparison of the three poisons of gonorrhoea, the chancroid 
and syphilis, so far as we are at present able to understand their 
nature, leads to the following conclusions. 

The only property common to them all is their communication, 
for the most part, by contact of the genital organs. 

The poisons of gonorrhoea and of the chancroid are alike in that 
their action is limited and never extends to the general system ; nor 
does one. attack afford the slightest protection against a second. 
They differ in that the poison of gonorrhoea may arise spontane- 
ously, while that of the chancroid, so far as we know, never thus 
originates ; that gonorrhoea chiefly affects the surface — true ulcera- 
tion being rarely induced — and, in its complications, most frequently 
attacks parts connected with the original seat of the disease by a 
continuous mucous surface, as the prostate, bladder, and testicle; 
while the chancroid, on the contrary, is an ulcer, involving the 
whole thickness of the integument or mucous membrane, and its 
complications are seated in the absorbent vessels and ganglia. It 
would also appear that the poisons of these two affections are 
limited to one common vehicle, viz., pus. Van Roosbroeck, on the 
authority of Rollet, has proved by experiment that if the discharge 
of gonorrhceal ophthalmia* be deprived of its pus-globules by filtra- 
tion, the remaining fluid is innocuous ; and Rollet states that he has 
obtained like results with the pus of chancroids. If these experi- 
ments can be relied on, they prove that the virus is not diffused 
throughout the purulent secretion, but is confined to the pus-globules 
which it contains. This conclusion is sustained by the fact that 



INTRODUCTION. 55 

neither the poison of gonorrhoea nor that of the chancroid ever 
reaches the general circulation, and it is well known that pus- 
globules are not capable of absorption. When the purulent matter 
of a chancroid enters the absorbent vessels, as occurs in the forma- 
tion of a virulent bubo, it is arrestecrby the first chain of lymphatic 
ganglia, and goes no farther. The paint used in tattooing is some- 
times conveyed to a ganglion in a similar manner ; 1 but neither in 
this case nor the former is there complete absorption. 2 

The syphilitic virus is alone capable of infecting the system at 
large, and of affording protection by its presence against subsequent 
attacks. Unlike the poisons of gonorrhoea and the chancroid, it is 
not limited to purulent matter, but exists in the blood, in the fluids 
of secondary lesions, in the semen, and probably in other secretions. 
The secretion of one form of chancre (the superficial variety), as 
shown by microscopical examination, is often entirely destitute of 
pus-globules ; 3 and the presence of the virus in secondary symptoms 
is proved by their power of contagion, and in the semen by the 
occurrence of hereditary syphilis in the offspring when the father is 
alone infected. 

There is no opposition whatever between these three poisons; 
they may all coexist in the same person, who may at the same time 
have gonorrhoea, a chancroid, and a chancre, or other syphilitic 
lesion ; hence we may explain a case related by Acton in which 
each of three students contracted one of these diseases from inter- 
course with the same woman on the same day. Two of these 
poisons may be present in the same fluid, as when the secretion of a 
chancroid or chancre mingles with that of gonorrhoea ; or as in the 
"mixed chancre" resulting from inoculation of the same part, either 
at the same time or successively, by the virus of the chancroid and 

1 Virchow has given a beautiful plate of the deposit of pigment matter in the 
axillary gland of an arm, the skin of which had been tattooed, and describes the 
process of absorption as follows: "A certain number of particles find their way 
into lymphatic vessels, are carried along in spite of their heaviness by the current 
of lymph, and reach the nearest lymphatic glands, where they are separated by 
filtration. We never find that any particles are conveyed beyond the lymphatic 
glands and make their way to more distant points, or that they deposit themselves 
in any way in the parenchyma of internal organs." (Cellular Pathology, English 
translation, p. 184.) 

2 Rollet, De la Plurality des Maladies Ve'ne'riennes, Gaz. M6d. de Lyon, No. 5, 
1860. 

* Mr. Henry Lee believes that a chancre is always an ulcer affected with specifio 
adhesive inflammation, and, unless irritated, destitute of pus-globules. Of 95 cases 
examined by the microscope at King's College Hospital, in none was the secretion 
purulent. (Medico-Chir. Trans, vol. xlii. p. 460.) 



56 INTRODUCTION. 

that of syphilis. The secretion of a chancroid or of a syphilitic 
lesion may also mingle with the other animal poisons, as the vaccine 
virus, and each will produce its usual effects unmodified by the pre- 
sence of the other. ^ 

DIVISION OF THE PRESENT WORK. 

Following the natural order suggested by the above considera- 
tions, I propose to divide the present work into three parts: the 
First treating of Gonorrhoea and its Complications ; the Second of 
the Local Contagious Ulcer of the Genitals, and its Complications ; 
and the Third of Syphilis. 



PAET I. 
GONORRHOEA AND ITS COMPLICATIONS. 



CHAPTER I. 

URETHRAL GONORRHOEA IN THE MALE. 

t 

Pkeliminary Considerations. — By far the ^most frequent dis- 
ease originating in sexual intercourse, is an affection of certain 
mucous membranes, a prominent symptom of which is an increased 
secretion and discharge from the diseased surface. At various times 
and places, this disease has received different names, founded on the 
prevailing ideas of the nature of the secretion referred to. At an 
early period in the history of Venereal, the discharge was supposed 
to consist of the semen, and hence the disease was called gonorrhoea, 
from ywv\, sperm, and psw, to flow ; a name which is still in use among 
American and English writers, notwithstanding the incorrectness of 
the supposition in which it originated. 1 The French call the same 
affection " blennorrhagie," or a flow of mucus, a name which is also 
erroneous, since the discharge does not consist of mucus alone, but 
of a mixture of mucus and pus. In popular language it is termed 
"clap" 2 by the English, and " chaude-pisse" by the French. 

The chief mucous membranes subject to gonorrhoea are those 
lining the genital organs in the two sexes, and the conjunctiva 
oculi. Gonorrhoea of the anus, mouth, nose, and external ear are, 
indeed, mentioned by authors, but the existence of all of them is 
more or less doubtful. Perhaps there is the least question in ad- 

1 Cockburnb (The Symptoms, Nature, Cause, and Cure of Gonorrhoea, London, 
1757) first established the fact that gonorrhoea is not a flow of semen. 

2 The term " clap" is said to be derived from the old French word clapier, indi- 
cating the low places where the disease is contracted. 

"Old French clapises, public shops kept by prostitutes. Hoblyn ; — clapiers, an old 
term for houses of ill fame." — Worcester's Dictionary. 

(57) 



58 URETHRAL GONOERH(EA IN THE MALE. 

mitting gonorrhoea of the anus and rectum, though it is said to be 
rare even in countries where unnatural practices are frequent ; but 
we can hardly admit under this head those cases in which the anus* 
is simply excoriated by a discharge flowing from the urethra or 
vulva, without extension of the disease to the rectum. 

Eeported cases of gonorrhoea of the mouth, nose, and external 
ear are very few in number, and are all of them open to serious 
question ; as, for instance, the supposed case of gonorrhoea of the 
nose, reported by Mr. Edwards, 1 in which it is very doubtful 
whether the disease was of this origin and not a simple catarrhal 
affection. M. Diday relates some experiments which will serve to 
elucidate this point, though we are surprised, in reading them, that 
any surgeon should presume to make them, or any patient submit 
to them. M. Diday says : " Frequently (eight or ten times at least), 
for the purpose of experiment, I have moistened the end of my 
finger in the urethral discharge of patients with gonorrhoea, when 
the disease was in its most acute stage, applied it within their 
nostrils and rubbed it into the nasal mucous membrane, and there 
has never resulted the slightest degree of inflammation in the part." 2 

But when we recollect how frequently a disregard of cleanliness 
must cause the application of gonorrhoeal matter to the nostrils and 
lips, and how readily such applications excite inflammation of the 
ocular conjunctiva, the great rarity of suspected cases of nasal and 
buccal gonorrhoea must convince us, without the necessity of such 
experiments as those above mentioned, that certain mucous mem- 
branes are more apt to contract gonorrhoea than others ; and in this 
we may find an analogy to an extraordinary fact which at one time 
excited much attention, viz., that all parts of the body are not 
equally susceptible of the two species of venereal ulcers ; the chan- 
croid never being met with upon the head or face, although it may 
be implanted there by artificial inoculation. The reason of the 
preference of these diseases for certain localities escapes us, but 
they are not the only instances of the kind met with. 

The symptoms and the treatment of gonorrhoea vary according 
as the disease affects the male or female, and according also to the 
portion of mucous membrane attacked ; it will be convenient, there- 
fore, to consider this affection under corresponding heads. 

1 London Lancet, Am. ed, June, 1857. 
* Annuaire de la Syphilis, annee 1858. 



SYMPTOMS. 59 



URETHRAL GONORRHOEA IN THE MALE. 

Men are more liable to contract gonorrhoea than women ; and of 
a given nnmber of cases of this disease in the former, in a large 
proportion it is the urethra which is affected. Cases of urethral 
discharge in the male outnumber all other forms of gonorrhoea iD 
the two sexes combined. The explanation of this fact will appear 
when we come to consider the causes and nature of gonorrhoea. 

Symptoms. — The symptoms of urethral gonorrhoea in the male 
first appear, as a general rule, between the second and fifth day 
after exposure ; though, in exceptional cases, as late as the seventh, 
tenth, or fourteenth day; but their occurrence after this time, as 
alleged by some authors, is, I believe, to be explained on the ground 
that the earliest manifestations of the disease have been* overlooked. 
At first, the symptoms are very slight, consisting only of an uneasy 
or ticklish sensation at the mouth of the canal, which, on examina- 
tion, is found more florid than natural, and moistened with a small 
quantity of colorless and viscid fluid, which glues the lips of the 
meatus together. This moisture of the canal gradually increases 
in amount, until on pressure a drop may be made to appear at the 
orifice ; at the same time it begins to lose its clear watery appear- 
ance, and assumes a milky hue. Examined under the microscope, 
it is found to consist of mucus with the addition of pus-globules ; 
the number of the latter being proportioned to the depth of color 
of the discharge. Meanwhile, some smarting is felt by the patient 
in the anterior portion of the canal during the passage of the urine. 

Such are the symptoms of the early stage o'f gonorrhoea. The 
exciting cause of the disease has been applied to that portion of the 
canal which lies near the orifice of the meatus and which was chiefly 
exposed to contagion, and the ensuing inflammation is gradually 
lighted up in this part, and has not yet extended beyond that por- 
tion of the urethra known as the fossa navicularis. This early 
stage of gonorrhoea is often called "the stage of incubation," a 
name which is objectionable because the inflammatory process is 
doubtless set up at the time of the application of the exciting cause. 
Time is required for it to produce its full effect, and the earliest 
symptoms are but slowly and gradually ushered in. A more appro- 
priate name is the first or preparatory stage. It is important to 
recollect the symptoms of this stage and the fact that the disease is 
as yet confined to the external portion of the urethra, since, as we 



60 URETHRAL GONORRHOEA IN THE MALE. 

shall see hereafter, a more rapid method of cure may now be 
resorted to than is admissible in the subsequent stages. 

The first stage of gonorrhoea usually lasts from two to four days. 
The symptoms gradually increase in intensity, until, in about a 
week after exposure, the second or inflammatory stage may be said 
to commence. If we examine the penis during this stage, we find 
the mucous membrane covering the glans, reddened and with an 
angry look. The whole extremity of the organ is swollen so that 
the prepuce fits more tightly than natural. In some cases the latter 
is puffed out by oedema in the cellular tissue, and phymosis may 
exist, rendering it impossible to uncover the glans. The inflamma- 
tory blush is especially marked in the neighborhood of the meatus, 
the lips of which are swollen so as to contract the calibre of the 
orifice. The discharge has now become copious, so much so in 
some instances as to drop from the meatus as the patient stands 
before you. ■ It is thick, of a yellowish cream color, and not unfre- 
quently tinged with green. This greenish hue, as in the sputa of 
pneumonia, is due to the admixture of blood-corpuscles, which may 
be sufficiently numerous to produce the characteristic color of 
blood. The penis generally, and especially upon the under surface 
over the course of the canal, is sensitive and tender on pressure. 

While passing his urine, the patient complains of intense pain 
which is now not confined to the auterior part of the canal, but is 
felt in all that portion of the organ anterior to the scrotum, or. is 
even more deeply seated. The severity of the suffering during the 
act is in some instances very great. The pain is compared to the 
sensation of a hot iron introduced within the canal, and the popular 
name, chaude-pisse, given to the disease by the French, is fully 
justified. This pain is excited in part by the irritation produced 
upon an abnormally sensitive membrane by the salts contained in 
the urine, but chiefly, I am inclined to think, by the distention of 
the contracted and sensitive canal by the passage of the stream. 
Hence, during the act, the patient involuntarily relaxes the abdomi- 
nal walls, forces the air from his lungs, and keeps the diaphragm 
elevated, in order to diminish the pressure upon the bladder and 
lessen the size and force of the stream of urine. In consequence 
also of the urethra being contracted and more or less obstructed by 
the discharge, the stream is forked or otherwise irregular. 

Another source of suffering in this stage of gonorrhoea is the 
nocturnal erections, which are apt to come on after the patient isr 
warm in bed. The genital organs are in a highly sensitive condi- 
tion, and are readily excitea by lascivious dreams, the contact of 



SYMPTOMS. 61 

the bedclothes, or a distended bladder; or, independently of such 
exciting cause, they assume a state of erection which even in health 
is more apt to occur during sleep. When thus excited, it will often 
be found that the penis is bent in the form of an arc with its 
concavity downward. This condition is known as chordee. Its 
explanation is very simple. The urethra, the chief seat of the 
inflammation, runs along the under surface of the penis. Plastic 
lymph is effused around the canal, gluing the tissues together and 
rendering this portion of the penis less extensible than the remain- 
ing portion composed of the corpora cavernosa. Hence, in a state 
of erection, the corpus spongiosum surrounding the urethra, not 
being able • to yield to the distention, acts like the string of a bow, 
and chordee is produced. The stretching of the parts thus ad- 
hering together excites pain, 'which is often very severe. The 
sufferer, awaking from sleep, instinctively grasps the penis in his 
hand, and bends it in a still smaller curve, so as to remove the 
strain from the under surface and thus ease the pain. I have been 
in the habit in my lectures of illustrating the mechanism of chordee 
by gluing a piece of tape along the surface of an india rubber 
condom, and then distending it with air or water. It not unfre- 
quently happens that during one of these attacks of chordee, the 
mucous membrane of the urethra becomes lacerated, and hemor- 
rhage takes place from the canal. In this way nature may produce 
local depletion, and if the flow be not excessive, the effect is often 
beneficial. 

The above explanation of the mechanism of chordee is the one 
usually received, though it is proper to state that it is rejected by 
Mr. Milton, who believes that chordee is due to spasm of the mus- 
cular fibres, which Kblliker and Mr. Hancock have shown to exist 
around the whole course of the urethra. 1 Milton's explanation is 
opposed by the fact that bending the penis so as to increase the 
curve of the arc affords partial ease to the pain of chordee, and I 
am not convinced that the generally received opinion should thus 
be laid aside, though it is highly probable that spasmodic muscular 
action plays some part in the production of the frequent erection? 
and chordee which take place in gonorrhoea. 

During the inflammatory stage of gonorrhoea abscesses sometimes 
form in the cellular tissue covering the urethra, either anteriorly 
to the scrotum, or in the perineum ; and may attain a very con- 
siderable size. If left to themselves, they are liable to break 

1 Milton on Gonorrhoea, p. 75. 



62 URETHRAL GONORRHCEA IN THE MALE. 

internally within the canal and give rise to urinary abscess and 
fistula. 

It is chiefly during the second stage of gonorrhoea that buboes 
are met with, if they occur at all ; for they are rare compared with 
the number of' patients afflicted with this disease. According to 
the statistics of the Antiquaille Hospital at Lyons, an attendant 
bubo is met with in one out of every fourteen cases of gonorrhoea. 1 
They are at once recognized by the physician and patient by the 
enlargement and tenderness of one or more glands in the groin, 
occasioning considerable pain and uneasiness in walking and stand- 
ing. Buboes attendant upon gonorrhoea, uncomplicated with chan- 
croid, are sympathetic buboes ; of which a fuller description will be 
given hereafter, when speaking of buboes in general. They may 
generally be made to disappear in a few days by keeping the patient 
quiet and producing a little counter-irritation by painting the skin 
over them daily with tincture of iodine. It is only in scrofulous 
subjects, or in consequence of violence, excessive fatigue or general 
depressing influences, that they ever exhibit a tendency to suppu- 
rate. I have known of one instance of a man suffering from gonor- 
rhoea, who after exposure to great hardship upon a wreck, had a 
suppurating bubo that confined him to his bed for six months. 

Inflammation of the lymphatic vessels running along the dorsum 
of the penis is still another complication of the acute stage of 
gonorrhoea, and one which is also met with in connection with 
chancroids. It is to be carefully distinguished, as we shall see here- 
after, from the induration of these vessels which often attends an 
indurated chancre. "It occupies the same vessels and the same 
situation, and presents the same forms as the latter ; but is distin- 
guished from it in several ways : 1. By its feel, which is like that 
of an hypertrophied cord, elastic but not cartilaginous. 2. By the 
fact that the cellular tissue uniting the vessels generally participates 
in the inflammation, and thus binds together in a large cord the 
dorsal vein, the lymphatics and the artery, rendering it difficult to 
distinguish the inflamed lymphatics from the bloodvessels. 3. By 
the pain, generally severe, which it excites, and by the swelling and 
redness visible over the course of the inflamed vessels, caused by 
the extension of the inflammation to the skin." 2 This inflammation 
of the lymphatics on the doisum of the penis sometimes gives rise 
to chordee, with the concavity of the arc looking upward. 

The second stage of gonorrhoea, which we have now described, is 

» Gaz. des Hopitaux, No 141, 1861. 

> Bassebeau: Affections dc la Peau Symptomatiques de la Syphilis, p. 160. 



SYMPTOMS. 63 

variable in its duration in different subjects. As a general rule, it 
lasts from one to three weeks, being influenced by the constitution 
of the individual, his mode of life and the number of his previous 
attacks. It is succeeded by the third stage or stage of decline. 
This final stage of acute gonorrhoea is marked by no peculiar symp- 
toms, and is characterized only by the disappearance of the more 
acute symptoms and a gradual return to a condition of health. The 
discharge runs through the same phases, in an inverse order, which 
it did at the outset of the attack. It gradually becomes less and 
less purulent, and finally is almost wholly mucous, before completely 
disappearing. 

Perhaps the most valuable indication of the ushering in of this 
stage of gonorrhoea is the marked diminution or entire cessation of 
the pain in passing water. The painful erections and chordee may 
continue after the acute inflammation has subsided, since it takes 
time for the plastic matter effused around the urethra to be ab- 
sorbed. 

We have reason to believe that in the course of an 'attack of 
gonorrhoea, the disease gradually extends from the outer to the 
deeper portions of the canal, and it is in this latter situation that it 
is prone to lurk for an indefinite period. After the discharge has 
lasted for several weeks, we may evacuate the whole of the spongy 
portion by pressure from behind forward in front of the scrotum, 
and then, when no further discharge can be made to appear, we can 
still produce it by the exercise of similar pressure on the perineum. 
In some instances, the inflammation extends to the mucous mem- 
brane of the bladder. 

The duration of the final stage of gonorrhoea is, as a general rule, 
longer than either of the preceding. It may be cut short by treat- 
ment, but, if left to itself, commonly lasts for weeks or even months. 
Gonorrhoea is a disease which, independently of treatment, rarely 
terminates in less than three months. 

Thus far I have said nothing of the reaction of this disease upon 
the general system. This varies greatly in different individuals and 
in different attacks in the same person. In some rare cases there 
is considerable febrile excitement during the inflammatory stage, 
marked by the usual symptoms of headache, dry skin, full pulse, 
furred tongue, etc. As a general rule, however, there is but little 
constitutional disturbance, and after the acute symptoms have passed, 
the invariable tendency of the disease is to depress the genera 1 
health. This fact should be remembered in the treatment. 

A first attack of gonorrhoea is usually more acute than subsequent 



64 URETHRAL GONORRHOEA IN THE MALE. 

ones; the latter often being subacute or chronic from the first. 
They are also more difficult to be influenced by remedies, and show 
a decided tendency to run into gleet. 

Cases of gonorrhoea have been reported, in which it has been said 
there was no discharge whatever — all the other symptoms of gonor- 
rhoea being present, and the disease following impure coitus. These 
have been called cases of dry gonorrhoea. I doubt whether there 
be a total absence of all secretion in these cases throughout their 
whole course, but can readily conceive of an inflammation of the 
mucous membrane of the urethra, resembling that of erysipelas 
upon the skin, in which the secretion is for a time but slight, and 
incapable of detection except by a careful examination of the urine. 
As the inflammation subsides, however, I should expect to find dis- 
tinct traces of a discharge. We have analogous symptoms occa- 
sionally in inflammations of the pituitary membrane of the nose. 
Two cases of this variety of gonorrhoea are reported by Dr. Beadle 
in the New York Journal of Medicine and Surgery, for October, 1840. 

Causes and Nature of Gonorrhoea. — Every one is aware that 
urethral gonorrhoea in the male often proceeds from direct conta- 
gion, or, in other words, from intercourse with a woman affected 
with the same disease. But there is another mode of origin, ad- 
mitted by nearly every writer, as of at least occasional occurrence, 
but with regard to the frequency of which some difference of opinion 
has been expressed. I refer to gonorrhoea originating in coitus just 
before, after, or during the menstrual period, or with a woman suffer- 
ing from leucorrhoea, and, in a few instances, when nothing whatever 
abnormal can be discovered in the female genital organs, and the 
disease in the male can only be attributed to the irritant character 
of the vaginal or uterine secretions. 

I have been convinced, by a somewhat extended observation, that 
gonorrhoea originating in this mode is of very frequent occurrence. 
Of one thing I am absolutely certain, that gonorrhoea in the male 
may proceed from intercourse with a woman with whom coitus has 
for months, or even years, been practised with safety, and this, too, 
without any change in the condition of her genital organs, percepti- 
ble upon the most minute examination with the speculum. I am 
c distantly meeting with cases in which one or more men have 
cohabited with impunity with a woman both before and after the 
time when she has occasioned gonorrhoea in another person ; or, less 
frequently, in which the same man, after visiting a woman for a long 
period with safety, is attacked with gonorrhoea without any disease 



CAUSES AND NATURE OF GONORRHCEA. 65 

appearing in her, and after recovery, resumes his intercourse with 
her and experiences no farther trouble. The frequency of such 
cases leaves no doubt in my mind, that gonorrhoea is often due to 
accidental. causes, and not to direct contagion. 

In many of the instances referred to, the woman is suffering from 
a frequent combination of symptoms met with in practice, viz., 
general debility, engorgement of the cervix uteri, and more or less 
leucorrhcea ; but her previous history, and the impunity with which 
her favors have been bestowed for a long period, preclude the idea 
that her discharge is the remains of a previous attack of gonorrhoea 
to which it owes its contagious property. Moreover, such an expla- 
nation fails to cover other instances, in which there is no appearance 
whatever of leucorrhcea, and the genital organs, so far as we can 
discover, are in a state of perfect health ; although intercourse about 
the time of the menstrual period has given rise to gonorrhoea in 
the male. 

An attempt is sometimes made to evade the issue of this question, 
by asserting that in the cases referred to, the disease has been con- 
tracted from another source than the one alleged, and the proverbial 
mendacity of venereal patients is appealed to in support of this 
assumption. Argument is of course useless with any one assuming 
this ground; but to a candid mind, the opinion of such men as 
Eicord, Diday, and others, who fully sustain the position above 
assumed, and who are certainly not ignorant of the sources of error 
surrounding the etiology of venereal diseases, is sufficient to carry 
great weight, and lead to an impartial investigation of facts which. 
I believe, can be followed but by one conclusion. For my own 
part, I desire to state that while pursuing the investigation which 
has led me to„believe in the frequency of gonorrhoea independent 
of contagion, I have not entertained a single case in which the 
moral grounds of certainty have not been irresistible; and that a 
number of my patients have been medical men, and intimate 
acquaintances, whose sins against morality were fully known to me, 
who could therefore have had no motive for concealment, and; with 
whom mistake or deceit has been either in the highest degree impro- 
bable, or, in repeated instances, well nigh impossible. Moreover, it 
is a mistake to suppose that in investigations of this nature we are 
entirely at the mercy of the patient's honor and truthfulness, since 
to one practising in a large city there are a thousand; sources of 
circumstantial evidence and remarkable coincidences in the testi- 
mony of persons wholly unknown to each other,, which in many 

cases preclude all possibility of error. 

5 



66 URETHRAL GONORRHOEA IX THE MALE. 

The greatest obstacle to the admission of gonorrhoea independent 
of contagion appears to be the rarity of urethritis in married men 
compared with the frequency of leucorrhceal discharges in their 
wives. As proved by unquestionable cases occurring in my own 
practice and in that of my medical friends, husbands do not always 
escape. That they are not more frequently affected, is sufficiently 
explained by the immunity conferred against all simple irritants by 
constant and repeated exposure, whereby "acclimation" — to use a 
term adopted by the French — is acquired. The same fact is observed 
when neither the church nor the state has sanctioned marital rela- 
tions ; since it is not generally the habitual attendant upon a kept 
mistress affected with leucorrhcea who suffers, but some fresh comer 
who shares her favors for the first time. 

My friend, Dr. B. Fordyce Barker, whose extensive experience 
with female diseases is well known, and who has thus had the op- 
portunity of studying this subject from an opposite standpoint to 
my own, tells me that he has noticed a peculiar form of inflamma- 
tion of the lining membrane of the uterus, in which the uterine 
discharge loses its alkaline reaction, becomes decidedly acid and 
acrid, and irritates and excoriates the mucous membrane of the 
vagina and the surface of the vulva. He adds, that, in numerous 
instances in married life, he has known this discharge to excite 
urethritis in the male between parties whose fidelity was unques- 
tionable ; and he has related to me a number in detail which I would 
gladly repeat, if space permitted. 

Most cases of gonorrhoea from leucorrhcea or the menstrual fluid 
present no characteristic symptoms by which they can be distin- 
guished . from those originating in contagion. The contrary is 
frequently asserted, and it is said that the former class may be 
recognized by the mildness of the symptoms, the short duration of 
the disease, and the absence of contagious properties. I am familiar 
with the slight urethral discharge unattended by symptoms of acute 
inflammation, and disappearing spontaneously in a few days, which 
sometimes follows intercourse with women affected with leucorrhcea ; 
but such instances are far less frequent than those in which the dis- 
ease is equally as persistent and as exposed to complications as any 
ease of gonorrhoea from contagion. Some of the most obstinate 
eases of urethritis I have ever met with have been of leucorrhceal 
origin, and hiave terminated in gleet of many months' duration. 
Diday has even set apart those cases of urethritis which originate 
ra the menstrual fluid as constituting a distinct class, characterized 



CAUSES AND NATURE OF GONORRHOEA. 67 

by their greater persistency and obstinacy under treatment than 
cases of gonorrhoea from contagion. 1 

Those who maintain the non-contagious character of urethral dis- 
charges of leucorrhoeal origin have failed to adduce the slightest 
proof in favor of their assumption, and it may safely be asserted 
that none of them would venture to make a practical application of 
their principles. The contagious character of the leucorrhoeal secre- 
tion is already proved by the existence of the disease in the male ; 
why should not the same property be continued another, still 
another, and any number of removes from its origin ? This suppo- 
sition is sustained by analogy, since no fact is better established 
than that catarrhal conjunctivitis may be communicated from one 
person to another until all the members of a family, school, or 
asylum have become affected. At our public institutions for dis- 
eases of the eye such instances are very common, and the physicians 
of our children's asylums are well aware of the difficulty of eradi- 
cating muco-purulent conjunctivitis which has once sprung up 
among the inmates. At an orphan asylum, under the charge of my 
friend, Dr. Learning, this disease was introduced by a single child, 
brought from Eandall's Island, and spread to twenty-two others 
before it could be arrested. Again, the leucorrhcea of pregnancy is 
sufficient to give rise to ophthalmia neonatorum : would any one, 
presuming upon its leucorrhoeal origin, dare to apply a drop from 
the infant's eyes to his own? Several instances are recorded in 
which physicians have lost the sight of an eye with which the dis- 
charge of ophthalmia neonatorum has inadvertently been brought 
in contact. 

The views which I have here advocated relative to the frequency 
of gonorrhoea independent of contagion, are by no means novel, 
and are entertained by many of our most eminent authorities, espe- 
cially among the French, who possess unequalled advantages for 
investigating the etiology of venereal diseases. The importance of 
the subject will fully justify me in making the following quotations 
from other authors. 

Eicord says : " If we investigate with the greatest care the exciting 
causes of gonorrhoea — and I am now speaking of the most charac- 
teristic cases of the disease — we cannot help admitting that a 
gonorrhoeal virus is absent in the majority of cases. Nothing is 
more common than to find women who have occasioned gonorrhoea 
unsurpassed in intensity and persistency, and attended by the most 

i Arch. G4n. de M6d., Oct., 1861. 



68 URETHRAL GONORRHffiA IN THE MALE. 

serious complications, and who are yet only affected with uterine 
catarrh which is sometimes hardly purulent. In many cases, inter- 
course during the menstrual period appears to be the only cause of 
the disease; while, in a large number, we can discover nothing, 
unless perhaps errors in diet, fatigue, excessive sexual congress, 
the use of certain drinks, as beer, or of certain articles of food, as 
asparagus. Hence the frequent belief of patients, which is very 
often correct, that they have contracted their gonorrhoea from a 
perfectly sound woman. 

"I am most assuredly familiar with all the sources of error in 
such investigations, and I will presume to say that no one is more 
guarded than I am against the various forms of deceit which are 
strown in the path of the observer ; yet I confidently maintain the 
following proposition : Gonorrhoea often arises from intercourse with 
women who themselves have not the disease. Any one who studies 
gonorrhoea without preconceived notions, is forced to admit that it 
often originates from the same causes that give rise to inflammation 
of other mucous membranes." 1 

The "preconceived notions" that Eicord here speaks of, have 
been the greatest obstacle to the admission of the truth in question. 
To a surgeon making up his mind beforehand that every patient 
utters a falsehood who says that he has contracted his gonorrhoea 
from a woman in whom no evidences of disease can be found, any 
amount of proof is valueless. 

Diday, in speaking of the prophylaxis of venereal diseases, says : 
"A man should never forget that gonorrhoea may be contracted 
from any woman ; and I say any woman, and not any prostitute, for 
I do not except from this uncivil remark, any member of the gentler 
sex. No matter how great her cleanliness, her apparent health, her 
supposed or real virtue, or even her virginity, or how recently she 
has been examined, a woman may, from some cause or other, have 
the whites — often of a very innocent character, as from metritis, 
chlorosis, dysmenorrhoea, catarrhal inflammation, or as a result of 
confinement, and also, on the other hand, from a gonorrhoea which 
she has contracted; and from the very fact that she has a discharge — 
no matter what its origin — she is liable to give a discharge to a man" 2 

Fournier arrives at the same result from an investigation- relative 
to the classes of women from whom gonorrhoea is derived. It ap- 
pears from his statistics that gonorrhoea was contracted from inter- 
course with — 

1 Lcttres sur la Syphilis, 2d ed., p. 29. 

2 NorreUes Doctrines sur la Syphilis, p. 515. The italics are in the original. 



CAUSES AND NATURE OF GONORRHCEA. 69 

Cases. 

Women of the town 12 

Clandestine prostitutes 44 

Kept women, actresses, etc 138 

Working girls 126 

Domestics 41 

Married women 26 

Total 387 

Fournier adds : " This result is easily explained, and might even 
have been predicted. In fact, gonorrhoea is, I think, much less 
frequently contracted from contagion than from excessive coitus, 
repeated or prolonged sexual congress, or peculiar excitement during 
the act; and in most cases of intercourse with public women, all 
these causes are absent, and intercourse is generally very short, 
without much excitement, and not frequently repeated." 1 

Again, Mr. Henry Thompson says : " It is a fact too well estab- 
lished to render it necessary to adduce evidence respecting it here, 
that urethritis in the male is sometimes caused by contact with the 
other sex, from discharges which are not venereal in their origin." 2 

Finally, from many other writers whose testimony is equally 
strong in favor of the leucorrhoeal and menstrual origin of gonor- 
rhoea in many cases, I will quote the remarks of Mr. Skey : — 

" I cannot entertain a doubt that a very considerable proportion 
of cases of gonorrhoea are not the product of a specific poison. The 
opinions I entertain on this subject are not the product of mere 
speculation, and still less of a desire to differ with other and more 
experienced authorities. They are deduced from, what appeared to 
my judgment, positive facts, and those by no means few or far be- 
tween. I may venture to say it is notorious that leucorrhoea will 
produce gonorrhoeal discharge; and if a poison be essential to 
gonorrhoea, whence comes it? Leucorrhoea is not supposed to 
contain the elements of gonorrhoeal poison. Again, gonorrhoea is 
by no means an infrequent result from intercourse about the period 
of menstruation ; and it also follows intercourse with women under 
circumstances of mechanical violence." 3 

The importance of the truth laid before the reader in the above 
remarks and quotations, whenever a physician in the exercise of his 
profession incurs the fearful responsibility of passing judgment 
upon the virtue of a woman, and thus affecting her reputation and 

1 De la Contagion Syphilitique, p. 118. 

2 Stricture of the Urethra, p. 120. 

3 Lectures on the Venereal Disease, London Medical Gazette, vol. xxiii. (1 838-9), 
p. 439. 



70 UKETHRAL GONO?KH(EA IN THE MALE. 

happiness (and often that of many others with whom she is con- 
nected) for life, cannot be overrated. In all such cases, the accused 
should receive the benefit of any doubt which may exist ; and the 
physician who withholds it from her out of a morbid fear that he 
may be imposed upon, 1 and thus runs the risk of convicting an inno- 
cent person, is unworthy of his calling. His province is to decide 
from the symptoms taken in connection with the known facts of the 
case, and unless these are sufficient to establish guilt beyond the 
shadow of a doubt, humanity demands at least a verdict of "not 
proven." The following cases will illustrate this point : — 

Case 1. A gentleman of the city, six weeks after marriage, applied 
to his physician to be treated for gonorrhoea, which he solemnly 
declared he had contracted from his wife, and his known probity was 
such as to render his statement in the highest degree probable. 
Under the supposition that his disease could only have arisen from 
contagion, he had already accused his wife of unchastity, her friends 
had been informed of the charge, and a separation and action for 
divorce were imminent. His physician examined the wife, whom he 
found perfectly healthy, and ascertained, on farther inquiry, that the 
disease in the husband was due to the continuance of coitus during 
a menstrual period. 

Case 2. The following case is reported in a work entitled " Sur la 
Non-existence de la Maladie Yenerienne," which was published in 
Paris in 1826 :— 

A young man became attached to a young female friend, " a peine 
sortie de l'enfance," and married her after some years of mutual 
attachment. Some months after this " hymen fortune !" the young 
man was compelled to take a journey to some distance, and, while 
travelling, he experienced pain in making water, and shortly per- 
ceived a discharge from the urethra. On arriving at a town, he con- 
sulted an eminent surgeon, who assured him he had a gonorrhoea. 
" Mais, monsieur, je suis nouvellement marieY' and he assured the 
learned surgeon, that he had never known any woman but his wife 
from the hour of his birth. " Comment," repond le chirurgien, en 
souriant, " vous voudrez me cacher la cause de votre mal : de quel 
pays etes-vous? Yos jeunes gens rougiroient; je vous certifie, mon- 
sieur, que vous avez une belle et bonne chaude-pisse." The youth 
continued to protest his innocence. Some days after the testicle 
swelled. 'The surgeon now assured him that if his wife were vir- 
tuous, he must have had " une affaire" with another woman, and that 

1 In a discussion upon the origin of gonorrhoea independent of contagion, which 
I once held with the writer of a work on yenereal, the final argument of my oppo- 
nent was, "I do not like to feel that I am imposed upon by patients." 



CAUSES AND NATURE OF GONORRHOEA. 71 

the pox remained in his blood from tliat period. Between the two 
alternatives of his own or his wife's purity, of course he could not 
entertain a doubt. He wrote to her an indignant and passionate 
letter, and then blew out his brains. The unfortunate woman sub- 
mitted to an examination, which proved her free from disease, never 
uttered another word — shortly miscarried, and died. So much for 
the honor of our noble profession ! 1 

Case 3. A few years since, in one of the New England States, a 
clergyman came very near being deposed from the ministry, and 
convicted of adultery, on the testimony of his physician, that a 
urethral discharge for which he had treated him could only have 
arisen from impure intercourse ! 

Other causes, in addition to those already mentioned, may give 
rise to urethral gonorrhoea in the nlale. Thus, unquestionable 
instances are reported in which a gouty or rheumatic diathesis 
without exposure in sexual intercourse has occasioned a discharge 
from the urethra. 

Eicord relates a remarkable case of tubercular deposit in differ- 
ent portions of the urethra of a strumous subject with symptomatic 
urethral discharge ; 2 and a scrofulous diathesis is generally a strong 
predisposing, if not an active cause of inflammation of the urethra 
as well as other mucous canals. 

Mr. Harrison reports the case of a medical practitioner who suf- 
fered from a puriform discharge, heat and pain along the course of 
the urethra, attended with frequent micturition, chordee, and sympa- 
thetic fever, after eating largely of asparagus. 3 

Among other causes of urethritis are free indulgence in fermented 
liquors, terebinthinate medicines, paraplegia inducing changes in 
the urine, the use of bougies, stricture, masturbation, prolonged 
excitement of the genitals, cancer of the womb, vegetations within 
the urethra, ascarides in the rectum, dentition, epidemic influences, 
etc. The internal use of cantharides is peculiarly liable to excite 
gonorrhoea, which, in this case, commences in the deeper portion of 
the canal. 

M. Latour, editor of the Union Medicate, vouches for the truth of 
the following story: A physician, thirty years of age, had been 
continent for more than six weeks, when he passed an entire day 
in the presence of a woman whose virtue he vainly attempted to 
overcome, but who resisted all his approaches. From ten o : clock 

1 Quoted by Mr. Skey, loc. cit. 

2 Bulletin de l'Acad. de Med., vol. xv., p. 565. 

3 London Lancet, Am. ed., Jan., 1860. 



72 URETHRAL GONORRHCEA IN THE MALE. 

in the morning until seven in the evening, his genital organs were 
in a constant state of excitement. Three days afterwards he was 
seized with a very severe attack of gonorrhoea, which lasted for 
forty days. 

A chancre within the urethra is attended with more or less thin 
and often bloody discharge, which will be more particularly de- 
scribed in a subsequent portion of this work. I will merely remark 
at present that inoculation of the secretion upon the person affected 
cannot determine the presence of an ulcer, unless it be a chancroid, 
since a chancre is not auto-inoculable. 

Again, urethral discharges are sometimes due to changes in the 
mucous membrane lining the canal, induced by infection of the 
constitution with the syphilitic virus. In several instances I have 
observed a muco-purulent discharge coinciding with the first out- 
break or a relapse of secondary symptoms, and so long after the 
last sexual act that it could not be attributed to the ordinary causes 
of gonorrhoea. Bassereau speaks of similar cases. 1 There is no 
more frequent seat of early general manifestations than the mucous 
membranes in general ; and in the cases referred to changes probably 
take place in the urethral walls similar to the erythema, mucous 
patches, and superficial ulcerations which are found within the 
buccal and nasal cavities. These cases are very rare, and can only 
be distinguished from ordinary gonorrhoea by the previous history 
and coexisting symptoms of the patient. For instance, if there has 
been no exposure for a long period, and especially if secondary 
symptoms have recently made their appearance upon other mucous 
membranes, the urethral discharge is probably symptomatic of the 
constitutional disease. Since the secretions of secondary lesions 
are now known to be contagious, the discharge in these cases is 
doubtless so, also; it is not susceptible of inoculation upon the 
person from whom it is derived nor upon any other affected with 
syphilis, but, if communicated to a healthy individual under the 
requisite conditions, will give rise to a chancre. 

The inferences from what has now been said of the etiology of 
gonorrhoea relative to its nature, are so obvious that they require 
little more than mere mention. If in a large proportion of cases 
the disease can be traced to no other cause than leucorrhoea, the 
menstrual fluid, or, in less frequent instances, to excessive coitus, 
intercourse under circumstances of special excitement, inattention 
to cleanliness, the abuse of stimulants, etc., and if, when thus ori- 

1 Affections Syphilitiques tie la Peau, p. 356. 



TREATMENT. 73 

ginating, it is undistinguishable either by its symptoms, course, 
complications, or termination, from the same affection due to con- 
tagion, it is evident that it should be ranked among the ordinary 
catarrhal inflammations of mucous membranes, or, in other words, 
that it is a simple urethritis, the connection of which with sexual 
intercourse is a merely accidental, or at all events, not a necessary 
circumstance. 

But — it may be asserted — the possibility of contagion proves ihe 
presence of a poison. Granted : but it does not follow that it is a 
specific poison, or one incapable of being produced by simple inflam- 
mation. Such a conclusion would be contrary to the facts adduced 
in the preceding pages, and, moreover, is not required by the analogy 
of inflammations of other mucous membranes ; since, in muco-puru- 
lent conjunctivitis — the true analogue of gonorrhoea — we have pre- 
cisely the same order of events, viz., inflammation originating in 
simple causes, and giving rise to a secretion which is contagious 
and capable of transmission through an indefinite series of indivi- 
duals. The discharge from the two mucous surfaces just mentioned 
would even appear to be transferable, since that from the urethra 
applied to the eye gives rise to purulent ophthalmia, the secretion 
of which, if we may rely upon a few experiments by Thiry, of 
Brussels, will, when brought in contact with the lining membrane 
of the urethra, produce urethritis. 

I have no space to discuss the untenable theory of a "granular 
virus" of gonorrhoea advanced by M. Thiry, according to whicn, 
the presence of granulations upon the mucous membrane is neces- 
sary to render the discharge contagious. 1 

Treatment. — The treatment of gonorrhoea must be adapted to 
the general condition of the patient, and especially to the stage of 
his disease. In the great majority of cases met with in practice, 
acute inflammatory symptoms have already set in at the time the 
patient first applies to the surgeon ; but in those exceptional cases 
which are seen at an early period, and in those only, we may often 
succeed in cutting short the disease by means of the treatment 
termed abortive. 

Abortive Treatment of the First Stage. — During the first few days 
after exposure, varying in number from one to five in different 
cases, before the symptoms have become acute, when the discharge 
is but slight and chiefly mucous, and while as yet there is no severe 

1 M. Thiry' s views have been published in a series of lectures in the Presse He'd. 
Beige, and are also advocated by Guy o mar, These de Paris, 1858 (No. 282). 



74 URETHRAL GONORRHCEA IN THE MALE. 

scalding in passing water, we may resort to caustic injections with 
a view of exciting artificial inflammation which will tend to subside 
in a few days, and supplanting the existing morbid action which is 
liable to continue for an indefinite period and is exposed to various 
complications. This is known as the " substitutive," or more com- 
monly as the "abortive treatment" of gonorrhoea. This method 
has been inordinately praised and as violently attacked; its true 
merit is probably to be found between these two extremes. It is 
certainly liable to be greatly abused, and, if so, is both unsuccessful 
and capable of producing the most unpleasant consequences ; but 
when limited to the early stage of gonorrhoea and used with proper 
caution, it is a highly valuable method of treatment, unattended 
with danger, and undeserving the censure sometimes cast upon it. 

In employing the abortive treatment, there are several points 
which it is important to recollect : 1. The disease, in the stage to 
which this treatment is applicable, is limited to the anterior portion 
of the urethra, known as the fossa navicularis, or extends but a 
short distance beyond it; it is not necessary, therefore, that the 
injection should reach the deeper portions of the canal. 2. For the 
treatment to be successful, the whole diseased surface should receive 
a thorough application of the injection, for if any portion remain 
untouched, it will secrete matter that will again light up the disease. 
3. When once a sufficient degree of artificial inflammation is ex- 
cited, the caustic has accomplished all that can be expected of it, 
and should be suspended. 

Since a solution of nitrate of silver, which is commonly used in 
the abortive treatment, is readily decomposed by contact with 
metallic substances, metal syringes should be avoided. Glass syr- 
inges, if well made, answer every purpose; but as found in the 
shops, they are apt to be unequal in calibre in different parts of 
the cylinder, the wadding of the piston contracts in drying, and a 
portion of the fluid fails to be thrown out, as is seen by its overflow 
when the syringe is filled a second time. For these reasons, I never 
advise a patient to purchase a glass syringe, knowing that it will 
probably give him much annoyance, and perhaps prevent his 
deriving benefit from treatment. Fortunately, we have a very 
excellent substitute in the hard-rubber syringes which can be 
obtained at the druggists'. 1 

1 An excellent series of urethral syringes is manufactured by the American Hard 
Rubber Company. In these instruments, the diameter of the cylinder is in all parts 
the same; the piston works with great accuracy; the material is not acted upon by 
ordinary medicinal agents, and the different sizes and forms of the instrument are 



TREATMENT. 75 

The solution of nitrate of silver, in the abortive treatment of 
gonorrhoea, may be of considerable strength, when only one injec- 
tion will be required ; or, it may be weak, and in that case should 
be repeated at short intervals until the effect produced be deemed 
sufficient. I much prefer the latter course, especially with patients 
who apply to me for the first time, since it enables me to graduate 
the effect according to the susceptibility of the urethra, which varies 
in different persons. The following is the formula for the weak 
form of injection : — 

R. Argenti nitratis crystalli gr. j-iss. 

Aquae destillatse 25 vj. 
M. 

•With this, as with all injections in gonorrhoea, it is essential to 
success that the surgeon should administer the injections to his 
patients, or see, by actual observation, that they know how to use 
them. Verbal directions cannot be relied upon. 

The patient should be made to pass his water immediately be- 
fore injecting, or, better still, a quarter of an hour before. We 
wish to clear the, urethra of matter, and to have the bladder empty 
so that the injection may have some time to act before it is washed 
away by another passage of the urine, and yet a short interval 
between the last act of micturition and the injection is advisable, in 
order that as much of the urine as possible may have drained from 
the canal and little be left to decompose the nitrate of silver. The 
prepuce should now be fully retracted, and the glans penis exposed. 
The latter should be wiped dry, so as to afford a firm hold to the 
thumb and forefinger of the left hand, applied to its opposite sides, 
and firmly compressing it around the point of the syringe, intro- 
duced to its full extent within the meatus. If this pressure be 
properly made, not a drop of the solution will be lost, as the piston 
of the syringe is slowly forced down by the forefinger of the right 
hand holding the instrument, and the whole contents will be dis- 

adapted to the various purposes for which it is required. The size most generally 
applicable to the treatment of gonorrhoea is called "No. 1, B." It holds half an 
ounce, which is not too much for injections in the latter stages of the disease ; if 
used in the abortive treatment of the first stage, it should be only half filled. " No. 
1 " holds two drachms, and is well adapted for the abortive treatment. " No. 1, A" is 
of the same size as the last mentioned, but has a very short nozzle, which is intended 
to obviate irritating the canal with the point of the instrument. The " Urethral 
Syringe with extra long pipe," is, in fact, a syringe united to a catheter, and is 
adapted for injections of the deeper portions of the canal or the bladder. The 
catheter portion may be bent to any curve desired, by first oiling it and heating it 
over a spirit lamp. 



76 URETHRAL GOXORRHCEA IK THE MALE. 

charged into the canal. The syringe should now be withdrawn, 
and the fluid still retained for a few seconds by continuing the com- 
pression of the glans. When the injection is allowed to escape, it 
will be found to be of a milky-white color. This is due to the 
partial decomposition of the contained salt by the remains of the 
urine and the muco-pus in the canal. As this decomposition has 
prevented the application of the injection in its full strength to the 
urethral walls, a second syringeful should be thrown in, and retained 
for two or three minutes. During this time a finger of the disen- 
gaged hand should be run along the under surface of the penis from 
behind forwards, so as to distend the portion of the canal occupied 
by the injection, and insure the thorough application of the fluid to 
the whole mucous surface. 

This description of the method of using the syringe is, in the 
main, applicable to all the injections which may be required in the 
course of a gonorrhoea ; but we are now speaking of the abortive 
treatment, by means of weak injections of nitrate of silver. We 
will suppose that this first injection has been administered by the 
surgeon, who, at the same time, has explained the varioiis steps of 
the operation to the patient. The directions with regard to diet, 
etc., that will presently be mentioned in speaking of the second 
stage, should now be given ; the patient should be ordered to repeat 
the injection every three hours, and, for the present, it is best that 
he should be seen by the surgeon twice a day. It is also well at 
this time to prescribe an active purge. 

This first effect of the caustic injections is manifested in a few 
hours ; the discharge becomes copious and purulent, and consider- 
able scalding is felt in passing water. In the course of twenty -four 
to forty-eight hours, however, the discharge grows thin and watery, 
and, very likely, is tinged with blood. It is now time to stop the 
injection and omit all medication for a few days, until we see how 
much good has been accomplished. If the treatment meets with 
its usual success the discharge will gradually diminish, and finally 
disappear in from three to five days. Sometimes, however, after 
growing less, it again increases, showing a tendency to relapse. In 
that ease, I usually advise weak injections of acetate of zinc, as 
recommended in the third stage of the disease. Some surgeons 
prefer to resume the caustic injections in the same manner as at first, 
if, after a week has elapsed, any traces of the discharge remain. 

The chief objection to this modification of the abortive treatment 
is, that it is necessary to leave the administration of most of the 
injections to the patient, who may be prevented by ignorance, or 



TREATMENT. 77 

the requirements of his occupation, from using them as thoroughly 
or as often as is necessary. If we have reason to fear this, we may 
resort to a stronger solution, and inject it once for all, with our own 
hands, but I have found the effect decidedly less satisfactory. It 
was this method of employing the abortive treatment that was 
recommended by Debeney of France, and Carmichael of England, 
by whom this treatment was first introduced to the profession. The 
same method is also still employed and highly recommended by 
many surgeons, and especially by M. Diday of Lyon. The strong 
injection should not contain less than ten grains of the nitrate of 
silver to the ounce of distilled water, and more than fifteen grains 
are objectionable, unless with patients who have been under treat- 
ment before, and in whom the urethra has been found to be quite 
insensible. 

R. Argent i nitratis crystalli gr. x-xv. 

Aquae destillatse ^j. 
M. 

The mode of using this injection is identical with that already 
described. Two small syringefuls should be thrown in ; the first to 
clear the urethra of urine and muco-pus, the second to exercise a 
curative effect ; and the surgeon should feel that the success of the 
treatment depends, in a great measure, on the thoroughness of its 
application. As an additional precaution against the fluid extend- 
ing further back than is necessary, the patient may compress the 
penis anteriorly to the scrotum, while the surgeon is administering 
the injection ; or the same result may be accomplished by making 
him sit astride the arm of a chair, and thus compressing the urethra 
in the perineum. 

There is still another mode of employing a strong solution of 
nitrate of silver, by means of an instrument introduced by Dr. F. 
Campbell Stewart, of this city, and called by his name. This 
instrument consists of a straight canula inclosing a sponge, which 
can be made to protrude from its extremity. This sponge is first 
soaked in a solution of nitrate of silver, and concealed within the 
canula. The instrument is then introduced for about two inches 
within the urethra, when the canula is to be partially withdrawn ; 
the sponge is thus exposed to the contact of the urethral walls, in 
which position it is to be allowed to remain for a minute or two, 
and then withdrawn by slowly twisting it on its long axis. By the 
use of Dr. Stewart's instrument, the extent of the application can 
be limited at will, and it is perhaps owing to this fact that we can 
employ with safety a much stronger solution than when using a 



78 URETHRAL GONORRHOEA IN THE MALE. 

syringe. I have thus applied a solution of twenty, and even thirty 
grains to the ounce, without exciting an undue amount of inflam- 
mation, or other unpleasant symptoms. Care should be taken that 
the instrument be of sufficient size. Some of those found in the 
shops are too small, not exceeding a No. 7 bougie in diameter. I 
have had one manufactured for my own use of the size of No. 10. 

I cannot leave this subject of the abortive treatment of gonor- 
rhoea, without again expressly stating that I recommend it only in 
the first stage of the disease, and not after acute inflammatory symp- 
toms have set in, or the patient suffers from scalding in passing 
water. Taking the usual run of cases as met with in practice, 
probably not more than one out of ten is seen at a sufficiently 
early period to admit of the abortive treatment. Its employment 
in the acute stage, as recommended by its inventors, is generally 
unsuccessful, and dangerous and even fatal results have been known 
to ensue. Prudent practitioners have limited the use of caustic in- 
jections to the early stage of gonorrhoea, except in some instances 
in the decline of the disease; but, in the latter case, the mode of 
injecting must be modified, so that the fluid may reach the deeper 
portions of the canal. 

Treatment of the Acute Stage. — The proper regulation of the diet, 
exercise, and mode of life of the patient, is of the first importance 
in every stage of gonorrhoea. In the treatment of the inflammatory 
stage, as well as in the abortive treatment of the first stage, if the 
patient can keep his bed for a few days, the battle is half won. The 
advantages of absolute repose and quiet should be placed promi- 
nently before him, and every. inducement be offered to lead him to 
avail himself of them. Yet in practice, we find that very few will 
submit to this constraint. It is very well to say that every patient 
that puts himself under the care of a physician, should follow his 
advice implicitly in all things; but we must take the world as we 
find it, and the calls of business, or the necessity of secrecy, often 
render the insistence upon such stringent rules impossible. When 
life is in danger, men absorbed in business will stay at home, but 
not merely for an attack of gonorrhoea. This, indeed, should not 
prevent our doing our best to persuade them, but we shall succeed 
in but a small minority of cases. 

Exercise of all kinds should be avoided as much as possible, 
walking, dancing, riding on horseback, and standing — in the street, 
at the desk, at a party — are all injurious. Eiding is certainly less 
objectionable than walking, and yet a long ride, even in a rail-car, 
often aggravates a gonorrhoea or induces a relapse when it is appa- 



TREATMENT OF THE ACUTE STAGE. 79 

rently cured. At home, and at the store or office, the recumbent 
posture should be maintained as much as possible. It is highly 
important, also, that the genital organs should be well supported by 
a suspensory bandage. The kind of bandage is immaterial, provided 
it fit well and do not chafe the parts; and of these conditions the 
surgeon should satisfy himself by actual observation. While the 
more acute symptoms continue, the diet should be exclusively fari- 
naceous ; and meat, stimulants, asparagus, cheese, coffee, and acids 
be forbidden. The perusal of all books calculated to excite the 
passions, and the company of lewd women, even if no improprieties 
be committed, should be strictly interdicted. The last-mentioned 
caution is not generally given without good reason. 

At the commencement of the treatment of a case of gonorrhoea 
in the acute stage, it is well to administer an active purge, as five 
grains of calomel combined with ten of jalap, a full dose of Epsom 
salts, or three or four compound cathartic pills of the U. S. P. If 
the inflammatory symptoms be severe, marked benefit will be de- 
rived from the application to the perineum of half a dozen leeches, 
which, however, are rarely absolutely necessary. Care should be 
taken to keep the head of the penis free from any collection of mat- 
ter, lest balanitis be excited or the disease aggravated by its pre- 
sence. A pair of triangular- shaped drawers, like ordinary swimming 
drawers, worn next the skin, affords the best protection to the 
patient's linen. Water, as hot as can be borne, is the most grateful 
local application that can be used. I have found that it generally 
affords great relief to the scalding in micturition and the local pain 
and uneasiness, and can fully indorse Mr. Milton's statement with 
regard to it. " The only direct application which I can safely say 
has never disappointed me, which is at once safe, simple, and use- 
ful, is that of very hot water to the penis. But to obtain the really 
good effects it offers, the water must be hot, not lukewarm. In fact, 
we seldom see so much good ensue as when it is carried to the ex- 
tent of producing some excoriation and faintness ; thus applied, and 
especially in the early stages of the disease, the weight felt about 
the testicles soon disappears, the pain on making water and using 
injections is soothed, and the prepuce and glans rapidly regain a 
more normal temperature and color." x The best method of employ- 
ing it is to direct the patient to immerse his penis in a cup of hot 
water for a few minutes before and after using the injection. 

After the operation of the cathartic, we may, in most cases, com- 

1 Milton on Gonorrhoea, p. 21. 



80 URETHRAL GONORRHOEA IN THE MALE. 

mence at once with copaiba or cubebs, rules for the exhibition of 
which will presently be given at length. If, however, the peois be 
still much swollen, and the scalding on passing water severe, we 
may defer the exhibition of the anti-blennorrhagics for a few ^ys, 
and administer alkalies or diuretics, either alone or combined with 
sedatives, for the purpose of rendering the urine less irritating by 
diminishing its acidity, or diluting its contained salts by increasing 
its quantity. Again, both these classes of remedies may be given at 
the same time. From one to two drachms of the chlorate, acetate, 
or nitrate of potash, or two or three drachms of liquor potassse, may 
be added to a pint of flaxseed tea ; and the patient be directed to 
take this quantity in the course of twenty -four hours. The follow- 
ing is also an excellent formula : — 

R. Potassae bicarbonatis £ij. 

Tincturae hyoscyami ^j. 

Mucilaginis 5 v. 
M. 

A tablespoonful every three hours. 

Do not mix tincture of hyoscyamus and liquor potassae in the 
same prescription, since the effect of the former is destroyed by the 
presence of a caustic alkali. 1 In this stage of the disease, Mr. Milton 
highly recommends the following : — 

R. Pulv. potassae chloratis gij. 
Aquae bullientis ^v. 

Misce et adde — 
Liquoris potassae ^iij. 
Potassae acetatis giij ad gv. 
Misce et cola. 
One ounce three times a day. 

If the bowels be not freely open, Mr. Milton adds powdered rhu- 
barb to each dose of this mixture, in sufficient quantity (gr. v ad 
9j) to produce two or three loose stools daily. The following is 
another formula recommended by Mr. Milton: — 

R. Potassae acetatis 5J. 

Spirit aetheris nitrici £iij. 

Aquae camphorae 3VJ. 
M. 
One ounce three times a day. 

1 See Paris's Pharmacologia, Ninth Edition, p. 512. This fact has recently been 
brought forward as new, and confirmed by actual experiment, by Dr. Garkod ; 
Mcdico-Chirurgical Transactions, Second Series, vol. xxiii. London, 1858. 



TREATMENT OF THE ACUTE STAGE. 81 

An elegant and convenient method of administering an alkali is 
by means of Brockedon's wafers of bicarbonate of potassa, of which 
two may be given after each meal. The only objection to them is 
their expensiveness. 

If the penis be much swollen and florid, the meatus contracted 
by the distention of its walls, and the urethra in a state of great 
sensibility, the above general measures should constitute the only 
treatment, and no local remedies, with the exception of hot water, 
be resorted to, until the inflammation has somewhat subsided. In 
the majority of cases, however, especially when the patient has had 
gonorrhoea before, the local symptoms are not severe, even in the 
acute stage, and the point of a syringe can be gently introduced 
within the canal without exciting much pain. When this is the 
case, an injection containing glycerin and strongly opiated, will be 
found to afford great relief to the local pain and uneasiness, and 
hasten the subsidence of the inflammatory symptoms, and the 
diminution of the discharge. I can speak very decidedly in favor 
of this application and of its perfect safety ; but the opium must 
not be added in the form of tincture, or the alcohol, which is an 
irritant, will counteract its effect ; and the fluid is to be injected 
with gentleness, and not with such force as to painfully distend the 
canal. The following is the formula that I use : — 

R. Extractii opii ^j. 
Glycerin gj. 
Aquae giij. 
M. 
Injection to be used after every passage of urine. 

In many cases of a subacute form, half a grain or a grain of acetate 
or sulphate of zinc may be added to each ounce of the mixture, 
even at the outset, and there are but few cases in which it is not 
admissible in the course of twenty -four or forty-eight hours, when 
the inflammation, local pain, and scalding are generally found to be 
much improved. If the case continue to progress favorably, the 
quantity of the astringent may be gradually increased, and that 
of the opiate diminished; and the treatment should be continued 
according to the rules laid down for the third stage, to be mentioned 
presently. 

"While pursuing the treatment of the acute stage of gonorrhoea, 
care should be taken that antiphlogistic measures be not too long 
persevered with. It should be remembered that the- natural ten- 
dency of the disease is to lower the tone of the system, and a conr 
dition of debility in turn reacts on the disease and prolongs its 

6 



82 URETHKAL GONORRHCEA IN THE MALE. 

duration. We often meet with patients who have treated them- 
selves with low diet and daily purging for weeks, and yet who are 
no better of their gonorrhoea. An antiphlogistic course alone may 
relieve the more acute symptoms, but it will not cure the complaint ; 
and so soon as the pain in passing water has diminished and the 
local inflammation in a measure subsided, the patient should no 
longer be confined to his room, and should have a more liberal 
diet; nor, under any circumstances, should his confinement and 
abstinence be prolonged, if, after a reasonable time, they are found 
to produce no change for the better, or the pulse becomes feeble, 
the skin clammy, anil the strength exhausted. Indeed, in some 
cases, in which the constitution is enfeebled by disease, debauch, or 
previous attacks of venereal, it is necessary to abstain from all 
measures calculated to lower the tone of the system, and resort to 
good living and even quinine, iron, and other tonics, from the very 
outset of the disease. It is, therefore, to be expressly understood 
that the antiphlogistic treatment here recommended, is intended to 
apply, in its full force, chiefly to the disease as it appears in first 
attacks in men of full habit. Those patients who have had numer- 
ous previous attacks will rarely require such active treatment in 
any stage of the disease. The judgment of the surgeon must deter- 
mine the indications of each individual case. 

Treatment of the Stage of Decline. — A marked diminution of the 
scalding in making water, and of the painful sensations in the penis, 
is, I believe, a better index of the subsidence of the inflammatory 
action, than the character of the discharge, which, independently of 
treatment, often continues copious and purulent after the third stage 
has fairly commenced. 

In giving directions as to the regimen of a patient -in the third 
stage of gonorrhoea, some regard should be paid to his usual mode 
of life. As a general rule, all indulgence in spirituous or malt 
liquors should be strictly forbidden, and total abstinence be prac- 
tised until the cure is complete, and for at least a fortnight afterward. 
You will meet with some patients, however, who have been free 
drinkers for years, and who will not well bear the total loss of their 
stimulus, without becoming so debilitated that their gonorrhoea is 
■thereby prolonged and more difficult to cure. In these exceptional 
cases, it is better to allow a glass of claret, sherry, or even brandy 
and water, to be taken with the dinner. In any case, malt liquors 
-should be avoided, since they are decidedly more injurious than 
other liquors which contain a larger amount of alcohol. The 
patient may now return to a more generous but simple diet, though 



TREATMENT OF THE STAGE OF DECLINE. 83 

salt meats, highly seasoned food, asparagus and cheese should still 
be avoided. The bowels are not to be allowed to become consti- 
pated, and this should be prevented so far as possible by regulating 
the diet. One or two free stools a day are desirable. If the patient 
have been confined to the house during the acute stage, he may now 
be allowed to go out, but should be cautioned against walking 01 
standing more than is necessary, and the genital organs should be 
well supported by a suspensory bandage. Patients often inquire 
whether the use of tobacco is injurious ; I believe that it is, and that 
either smoking or chewing, especially in excess, relaxes the genital 
organs and tends to keep up a urethral discharge. I have frequently 
been told by patients subject to spermatorrhoea, that smoking during 
the evening would invariably be followed by an emission during 
the night, and I am satisfied that many cases of gonorrhoea are pro- 
longed by the excessive use of tobacco. I therefore recommend 
entire abstinence, or, at least, great moderation, both in smoking and 
chewing, to persons suffering with this disease. 1 

The chief remedies adapted to the third stage of gonorrhoea are 
injections, and copaiba and cubebs. By far the more important of 
these are injections, which constitute our chief reliance in the treat- 
ment of this affection, when it has arrived at this stage; and, in 
spite of all that has been written and said against them, I do not 
hesitate to say, that the surgeon who voluntarily renounces injec 
tions, deprives himself of his best weapon in contending with gonor- 
rhoea, and is comparatively impotent in his attempts to conquer it. 

The objections that have been raised against this mode of treau 
ment need not long detain us. They are chiefly the following: 
1. It is asserted that the injected fluid carries before it the muco-pus 
within the urethra, and thus extends the disease to the deeper por 
tions of the canal. Supposing this possible in any case, it cannot 
take place, if the patient pass his water before injecting, as he should 
always be directed to do. 2. It is said that injections may excite 
swelled testicle and other complications of gonorrhoea. This is 
only possible, when they are used of too great strength or with 
undue violence. 3. It is supposed by some persons that there is 
danger of the injection penetrating the bladder; but this idea is 
entirely groundless. It is absolutely impossible to inject the bladder, 
however great the amount of force employed, by means oi a syringe 
merely introduced within the meatus. A knowledge of the anat- 

1 Dr. Shiplkt has recently published two cases of gonorrhoea in which tne dis- 
charge repeatedly disappeared on leaving off smoking, a wd itUxiatn. on Atoning it. 
[Boston Med. and Surg. Journal, Nov. 22, 1860.) 



84 URETHRAL GONORRHCEA IN THE MALE. 

omy of the canal is sufficient to establish this point and experience 
coDfirms it. Moreover, no harm would ensue even if a portion of 
the fluid should enter this viscus, for it would be immediately neu- 
tralized by the urine. 4. The chief objection that has been alleged 
against injections is, that they are a frequent cause of stricture of 
the urethra. This the opponents of injections have endeavored to 
prove, by showing that most persons with stricture preceded by 
gonorrhoea, were treated for the latter disease by injections. This 
is clearly a mode of reasoning, post hoc ergo propter hoc, and by no 
means proves the ground assumed. I have heard of some one, who, 
to show its fallacy, instituted some inquiries among patients with 
stricture, as to whether they had taken flaxseed tea for their previous 
gonorrhoea, and who was able to prove, if such reasoning be reliable, 
that flaxseed tea is a very fruitful source of stricture. As Eicord 
justly states, it is much more probable that strictures are due to the 
chronic inflammation, which, in cases of gonorrhceal origin, has 
usually preceded them for a long period, than to any influence exer- 
cised by injections. This well known effect of chronic inflammation 
of a mucous membrane in producing an effusion of plastic material 
in the sub-mucous cellular tissue which by its contraction dimin- 
ishes the calibre of the canal, is a strong argument in favor of this 
view. The objections to the use of injections are, I believe, founded 
on their abuse, or on false reasoning, and will not stand the test of 
examination. When properly used, they constitute the most valua- 
ble means within our reach for the cure of gonorrhoea, and are 
employed in the practice of all surgeons, with very few exceptions, 
who have had the opportunity of testing their value. 

Injections are particularly adapted to the treatment of the first 
stage by the abortive method and to the treatment of the third stage 
of gonorrhoea ; although, as already stated, in very many cases they 
may be used with safety and benefit in a weak form, even in the 
second or acute stage. 

These remarks in favor of injections do not of course imply that 
they are infallibly successful, nor that they can be used indiscrimi- 
nately in all cases. Under certain circumstances, their effect is 
found to be injurious. If in the course of treatment the patient 
complain of a frequent desire to pass his urine, and other symptoms 
indicating irritation or inflammation of the neck of the bladder or 
prostate, injections should be at once suspended. Continuous pain 
in the penis, or any considerable amount of tumefaction of its tissues 
also contra-indicates the use of irritant or astringent injections, 
although the formula containing glycerin and extract of opium, 



TREATMENT OF THE STAGE OF DECLINE. 85 

which was recommended in the acute stage, may still, in many cases, 
be employed with advantage. Moreover, it should not be forgotten 
that injections will sometimes keep up a discharge through the 
irritation which they excite, however simple may be their composi- 
tion. After the force of the disease has been subdued, they should 
therefore be used at gradually increasing intervals, or, from time 
to time, be altogether omitted, until the necessity of their continu- 
ance again becomes apparent. 

The manner of using the syringe in the third stage is essentially 
the same as in the abortive treatment of the first stage. A larger 
syringe, however, should be employed, one, for instance, holding 
three or four drachms ; since there is now no necessity of limiting 
the action of the injection posteriorly, and, on the contrary, it is 
desirable to extend it as far back as possible, in order that it may 
reach the whole diseased surface. For this purpose the finger may 
be run along the under surface of the urethra from before back- 
wards, as well as in the opposite direction (from behind forwards), 
as previously recommended, in order to insure complete distention 
of the canal and exposure of its lucunse. The patient should always 
pass his water before injecting, and throw in two syringefuls at each 
application. 

A great variety of substances have been recommended as the 
active principles of injections. A choice, to a certain extent, is 
doubtless desirable, since the same injection does not always suc- 
ceed equally well in all cases. For instance, one of my patients, 
whom I have repeatedly treated for gonorrhoea, is always made 
worse by an injection of sulphate of zinc, and is benefited by a 
weak solution of nitrate of silver. Peculiarities of this kind are 
occasionally met with, but I believe that much time is wasted by 
young practitioners in changing from one to another of the many 
varieties of injections proposed in books, under the supposition that 
some specific effect is to be obtained from the contained ingredients, 
whereas, in most cases, success depends upon the thoroughness of 
the application, and attention to the general health and any existing 
complications. 

My own preferences for an astringent in the active principle of 
injections in the third stage of gonorrhoea, are very strongly in favor 
of the sulphate of zinc ; which is also the favorite injection of Sig- 
mund of Vienna, Mr. Milton, and many other eminent surgeons. I 
have already spoken of the addition of a small quantity of this salt 
to the sedative injections of the acute stage, after the more inflam 
matory symptoms have been subdued. The proportion of the su] - 






86 UKETHEAL GONOEEHffiA IN THE MALE. 

phate may be increased and that of the opiate diminished, as the case 
progresses, and the latter finally omitted altogether. The strength 
of the injection should be such that it may excite a slight uneasy 
sensation in the urethra for about ten minutes, but it must not be 
strong enough to cause severe or long-continued pain. As the case 
approaches a cure, the injection will cease to excite any unpleasant 
feeling whatever, and its strength need not be further increased. In 
most cases, we need not at any period exceed the proportion of the 
sulphate in the following formula : — 

/ R. Zinci sulphatis gr. xij. / '/. 

Aquae §iv. £j 

M. 

Glycerin may be substituted for half an ounce or an ounce of the 
water. As to the frequency with which the injection is to be used, 
I usually direct the patient to inject after each passage of his urine, 
with the expectation that he will take four or five injections in the 
course of the twenty-four hours. It is better that the last injection 
should be applied an hour or two before retiring, since if used di- 
rectly before going to bed, it favors the occurrence of erections and 
chordee during the night. 

If the discharge do not materially diminish under the use of these 
injections, either alone or combined with the internal administration 
of copaiba or cubebs, I usually resort to a solution of nitrate of silver, 
of the strength of from two to five grains to the ounce of water, and 
inject it myself for the patient, daily, or every two or three days, 
while at the same time he is directed to continue his injection of sul- 
phate of zinc. The effect of an irritant like nitrate of silver should 
be closely watched, and its administration should not, therefore, be 
left to the patient himself. 

The acetate of zinc is nearly, if not quite as valuable a remedy as 
the sulphate, and the remarks above made in favor of the latter are 
equally applicable to the former. Indeed, if I were asked to name 
the simplest treatment of gonorrhoea, and the one best adapted to the 
largest number of cases, I should reply : a weak injection of the sul- 
phate or acetate of zinc, containing from one to three grains to the 
ounce of water. Many men about town constantly carry in their 
pockets a prescription of this kind (generally with the addition of a 
little morphine- or a few grains of powdered opium), with which they 
almost invariably succeed in arresting their frequent attacks of 
gonorrhoea, without resorting to the nauseous anti-blennorrhagics, 
or finding it necessary to consult a surgeon. A great reputation has 
been acquired for a reddish powder sold by an irregular practitioner 



TREATMENT OF THE STAGE OF DECLINE. 87 

of this city, who tells his patients that the ingredients are entirely 
unknown to the profession. This powder, subjected to chemical 
analysis, is found to contain as coloring matter Armenian bole, and 
as an active ingredient acetate of zinc. 

The sulphate of zinc was a favorite with Dr. Graves, who was in 
the habit of combining it with the impure carbonate of zinc, as in 
the following formula : — 

R. Zinci sulphatis gr. iij. 3 /" 

Calaminae gr. x .— — /Q //f tf%**~ <E~-*- 

Mucilaginis gij. — — — — ~ " ' 

Aquas ^vj. — y/^£ ^Vi ^ C-**— 

M. 

"With regard to the addition of calamine, Dr. Graves says : " How 
the lapis calaminaris acts, unless on a mechanical principle, it is diffi- 
cult to explain ; but of its utility I am certain, having long used this 
combination, as recommended in Thomas's Practice of Physic." 1 

The chloride of zinc is a powerful caustic and irritant which ful- 
fils, although in a much less perfect manner, the same indications as 
nitrate of silver, and may, therefore, be used under similar circum- 
stances. It is a favorite injection with some practitioners, and espe- 
cially with my venerable friend, Dr. J. P. Batchelder, who employs a 
very strong solution in all stages of gonorrhoea, and states that bat ,j 
few cases resist more than a week. Dr. B. dissolves gij of the chlo- 
^ ride in 3iij of water, and directs the patient to commence with three 
drops of the mixture to a tablespoonful of water, and inject three 
times a day ; to add a drop at a time (rarely exceeding eight drops) 
until a smarting sensation is produced ; and then gradually to dimin- 
ish the strength until the discharge disappears. 

Of the numerous other formulae for injections sometimes employed 
in the treatment of gonorrhoea, the following are among the best : — 

R. Cupri sulphatis gr. xij. 
Aquae ^iv-vj. 



M 



M. 



Liq. plu'mbi subacetatis ^ss-j. 
Aquae ^iv-vj. 



R. Aluminis gr. xij-xxx. 

Aquae ^iv. 
M. 

Mr. Milton says of alum : " The absence of pain which follows it** 
use, and its feeble curative power, have led me to assign to it only a 

i Clinical Lectures, London Med.Gaz., new series, vol. i., 1838-9, p. 438. 



86 URETHRAL GONORRHCEA IN THE MALE. 

secondary rank. I am, indeed, extremely doubtful, if it possess any 
superiority over very mild injections of nitrate of silver or sulphate 
of zinc, and would, therefore, confine its exhibition to those cases 
accompanied by severe pain, where it may, during a day or two, 
serve as a pioneer to the others." 

In the following we have a combination of alum and sulphate of 
zinc : — 

R. Liq. aluminis comp. Sjj. 

Aquae Sjiij. 
M. 

The two following are excellent formulae much employed by 
Eicord : — 

R. Zinci sulphatis, 

Plumbi acetatis, aa gr. xxx. 

Aquae rosae ^vj. * 

M. 

R. Zinci sulphatis gr. xv. 

Plumbi acetatis gr. xxx. 

Tincturae catechu, 

Vini opii, aa gj. 

Aquae rosae ?vj. 
M. 

Vegetable astringents may also be employed either alone or in 
combination with the salts of the metals. 





R. 


Vini rubri J;vj. 
Acidi tannici gr. 


xviij. 






M. 










R. 


Zinci sulphatis, 
Acidi tannici, aa 


gr. xij, 






M. 


Aqu83 j|iv. 






Tannate of 


zinc is formed by decomposition 


of the i 


3ulphate. 



Injections of tincture of aloes are recommended by Gamberini, 1 
of Bologne, who states that they excite only a momentary smarting 
sensation, and are very efficacious. 

R. Tinct. aloes ^ss. 

Aquae 3iv. 
M. 

The subnitrate of bismuth has recently come into favor. It acts 
as a local sedative, or, when deposited upon the walls of the urethra, 
may possibly serve to protect the diseased surfaces from contact. Of 
52 patients treated exclusively with injections of subnitrate of bis- 
muth, 36 recovered after an average treatment of twenty-two days. 2 

1 Rev. de The*r. Med.-Chir., Jan. 1, 1860, p. 13. 

1 Victor de Mekic; Report to the Medical Society of London, April 30, 18G0. 



COPAIBA AND CUBEBS. 89 

I have found only one difficulty attending its use, viz., that it 
clogged up the urethra, and by its mechanical presence excited an 
uneasy sensation, which was only relieved by the passage of the 
urine. As it is not soluble in water, it should be suspended by 
means of mucilage, or glycerine, and the bottle be shaken before 
using. 

R. Bismuthi subnitratis gij. 

Mucilaginis ^ss. 

Aquae giijss. 
M. 

Dr. Irwin (U. S. Army) relies upon an injection of chlorate of 
potassa (si ad aquae 3viij), repeated every hour for the first twelve 
hours, and gradually decreasing the frequency until the second or 
third day; when he states, " the disease will be generally found to 
have ceased." 

Mr. Gr. Borlase Childs employs an injection of the liquor hydrar- 
gyri nitratis (tt[ss ad aquae 3i), repeated three times a day. 

Western eclectics, so-called, often use hydrastin, either alone or 
combined with leptandrin. 

R. Hydrastin gr. x. 

Leptandrin gr. iv. 

Aquae ^iv. 
M. 

Finally, in many cases of gonorrhoea, simple iced- water injected 
after each passage of the urine, is very serviceable in allaying pain 
and irritation, and not inefficacious for the cure of the discharge. 

Copaiba and Gubebs. — Certain drugs which appear to possess a 
peculiar power in arresting inflammation of the urethral mucous 
membrane, are called anti-blennorrhagics. The chief of them are 
copaiba and cubebs. Some interesting investigations made by 
Bicord to determine the mode of action of these agents, are given 
in Eicord and Hunter on Venereal. It had already been observed 
in practice that copaiba and cubebs had but little curative effect 
upon gonorrhoea of any portion of the male or female genital 
organs, except the urethra ; and it was hence suspected that they 
acted chiefly by their presence in the urine, and not through the 
general circulation; but this fact had not been demonstrated. A 
man with gonorrhoea chanced to enter Eicord's ward at the Hopital 
du Midi, who had a fistulous opening communicating with the ure 
thra a short distance in front of the scrotum, produced by a ligature 
which had been applied around his penis when a child. He could 
at will, by separating or approximating the two edges of the fistula, 



90 UKETHRAL GONORRHOEA IN THE MALE. 

either make his urine emerge from the artificial orifice, or cause it 
to traverse the whole extent of the urethra. Both portions of the 
canal were affected with gonorrhoea. 

Eicord administered copaiba to this patient, and directed him to 
pass his water entirely through the fistula. In the course of a few 
days, the disease was cured in the posterior portion of the canal, 
behind the artificial opening through which the urine had passed, 
while it remained unchanged in the anterior portion. He was now 
directed to make •his water pass through the whole length of the 
canal, and in a few days more the anterior portion was also cured. 
By a singular coincidence, two other cases, of a similar character, 
soon after presented themselves in Eicord's wards, in one of which 
copaiba, and in the other cubebs, was given in the same manner, 
and the result in each was the same as in the case just described. 
From these experiments, Eicord concludes that copaiba and cubebs 
have but little influence upon gonorrhoea, unless directly applied to 
the diseased surface, and hence that we cannot expect decided benefit 
from their administration in any form of gonorrhoea, except that of 
the urethra in the two sexes. In gonorrhoea of the vagina or vulva, 
or in balanitis, they are comparatively useless. 

The presence of these drugs in the urine is still further evinced 
by the odor which they impart to this fluid, and which is often suffi- 
cient to pervade the bedchamber occupied by the patient. 

It must not, however, be inferred that copaiba and cubebs have 
no effect except by way of the kidneys. They are often used with 
benefit in other diseases than those of the urinary organs, and 
cannot therefore be entirely destitute of action through the general 
circulation. Moreover, they sometimes act as revulsives by pro- 
ducing copious evacuations from the bowels, and the urethral dis- 
charge is diminished as after the administration of a purge ; their 
chief action, however, is in the manner described, by their presence 
in the urine. 

Such being the case, it might naturally be supposed that an emul- 
sion of copaiba injected into the urethra would have the same effect, 
and that thus the internal administration of so nauseous a druo - 
might be avoided. The experiment has been tried in numerous 
io stances, but the result has always been unsatisfactory. As stated 
by Eicord, both copaiba and cubebs, in passing through the diges- 
tive organs or kidneys, undergo some modification of an unknown 
character, upon which their curative power depends, and which 
cannot be imitated by art. 

Dr. Hardy, of Paris, is said to have effected a cure in several 



COPAIBA AND CUBEBS. 91 

cases of vaginal gonorrhoea by giving the patients copaiba, and 
directing them to inject their urine into the vagina after each act 
of micturition. This course, however, is more interesting as an 
experiment than worthy of imitation in practice. 

M. Eoquette, of Nantes, states that he has cured two patients who 
happened to be rooming together, by giving copaiba to one of them 
and directing the other to inject his friend's urine. 1 Testimony on 
this point, however, is not uniform. In a recent number of the 
Gaz. Med. de Lyon, 2 Diday says : " We seize the present occasion 
to confess, that injections, and even the retention within the urethra., 
of urine containing copaiba — a mode of treatment proposed by our- 
selves in 1843 — has not had in our hands the same success as 
reported by other authors, or as theoretical considerations would 
lead us to expect." 

It was formerly supposed that copaiba could be used with safety 
only in gleet, and even then in very small doses, and that it was 
inadmissible in gonorrhoea, especially in its acute stage, having a 
tendency, as was thought, to excite inflammation of the neck of the 
bladder and swelled testicle. In the latter part of the last century, 
however, it was discovered that the natives of South America were 
in the habit of administering copaiba in large doses in all stages of 
gonorrhoea, and this, too, with very great success. This led to a 
bolder method of administering it, and it was soon ascertained that 
its curative effect is much greater in the acute than in the chronic 
form of urethritis, and that it is rarely, if ever, productive of those 
complications which were once attributed to it. 3 In short, it would 
appear that copaiba can be administered with safety and to much 
greater advantage in the acute stage of gonorrhoea, or at an early 
period of the stage of decline than afterward, and the same is true 
of cubebs. Still, when a case of this disease presents itself with 
marked inflammatory symptoms, it is usual to wait for a day or two 
until these have been somewhat subdued by the means already 
mentioned, before commencing with copaiba or cubebs, and I do 
not think that any time is thus lost ; and, in all cases, the effect of 
the remedy is promoted by the previous exhibition of a cathartic. 
The diuretics and alkalies, spoken of in connection with the acute 
stage, may be combined with these drugs, as in some of the formulae 
to be mentioned presently, or may be given separately. 

1 Accidents Determines par le Copahu, L'Union Mdd., Dec. 19, 1854. 

2 For June 16, 1863. 

3 For an interesting history of the remarkable change in medical opinion with 
regard to the administration of copaiba, see Trousseau, Traite" de Therapeutique, 
vol. ii. p. 592. 



92 URETHRAL GONORRHOEA IX THE MALE. 

The dose of copaiba is from twenty minims to one or even two 
drachms, repeated three times a day. It may be given in its pure 
state upon coffee, wine, or milk, but it is so disagreeable to the palate, 
and so likely to excite nausea, eructations, and even vomiting, that 
lew persons can tolerate it in this form. To render it more accept- 
able to the taste and stomach, it is generally given in combination ; 
and other ingredients are often added for the purpose of assisting its 
action upon the urethra. The " Lafayette mixture " in common use 
may be made much more acceptable to the palate by the addition of 
extract of liquorice, as follows : — 

R. Copaibae ^j. 

Liquoris potassae ^ij. 
Ext. glycyrrhizae ^ss. 
Spiriti aetheris nitrici ^j. 
Syrupi acacias t ^vj. 
Olei gaultheriee gtt. xvj. 
Mix the copaiba and the liquor potassae, and the extract of liquorice and sweet 
spirits of nitre first separately, and then add the other ingredients. 
Dose. — A tablespoonful after each meal. 

The following are also useful formulae — 

R. Olei copaibae, 

" cubebae, aa 3J. 
Aluminis £ij. 
Sacchari albi £iv. 
Mucilaginis giij. 
Aquae ^ij. 
M. 
Dose. — A teaspoonful three times a day. 

R. Copaibae, 

Liquoris potassae, aa ^iij. 
Mucilaginis acaciae ^j. 
Aquae menthae viridis q. s. ad ^vj. 
M. (Milton.) 

Dose. — One ounce three times a day. 

R. Copaibae gx. 

Tincturae cantharidis, 
Tincturae ferri chloridi, aa ^ij. 
M. 
Dose. — From half a teaspoonful to a teaspoonful. 

But in whatever way combined, many stomachs will not tolerate 
copaiba in a liquid form ; hence I commonly prescribe the solidified 
mass, formed by the addition of magnesia, and known in the U. S. 
Divp&rwtory as Pilulae Copaibae. It requires some little tact to pre- 
pare this mass ; or, rather, difficulty is met with, unless the proper 
kind of copaiba be used. Two kinds of the balsam are found in 
commerce, one of which, the best, is solidifiable with magnesia, and 



COPAIBA AND CUBEBS. 93 

the other not. The solidified mass should be divided into pills, each 
of which may contain five grains ; and it is desirable to coat them 
with sugar, both for the purpose of preventing their adhering 
together, and to render them more acceptable to the palate. This is 
to be accomplished in the following manner : Put the pills into a 
vessel with sufficient water to moisten them ; then turn them out 
upon a pan and sprinkle over them finely powdered sugar, at the 
same time rolling them about by shaking the pan, so that they may 
be entirely and equally coated. This process may be repeated after 
they are dry, as many times as is necessary to give them a thick 
coating of sugar. The dose is from four to eight pills three times a 
day. Thus prepared, they leave no taste in the mouth, and, being 
slowly dissolved in the stomach, are much less likely to excite nau- 
sea than the liquid article. 

We have another anti-blennorrhagic, but little if at all inferior to 
copaiba, in the powdered berries of the Piper Cubeba. Cubebs pos- 
sess the advantage over copaiba of being far less disagreeable to the 
taste, and less likely to excite nausea, eructations, vomiting, and 
diarrhoea ; and, on this account, are often to be preferred in the treat- 
ment of gonorrhoea. They cannot be relied upon, however, unless 
freshly powdered, and preserved in a glass vessel ; since the essential 
oil which they contain is rapidly absorbed by any porous material. 
Cubebs are conveniently taken, mixed in sweetened water, in the 
proportion of one to two drachms of the powder to half a glassful of 
the liquid ; and this dose should be repeated three or four times a 
day. 

Cubebs are often advantageously combined with iron, especially 
for persons of weak habit, thus : — 

R. Pulveris cubebse gij. 
Ferri carbonatis ^ss. 
M. et ft. pulv. 

To be taken three times a day. 

Cubebs and copaiba may be combined together in the same pre- 
scription. 

R. Copaibse Jij. 

Pulveris cubebae 3J. 

Aluminis ^iss. 

Magnesiae q. s. at fiat ma»sa. 

To be divided into pills containing five grains each, of which from four to eight 
arc to be taken three times a day. 



94 URETHRAL GONORRHOEA IN THE MALE. 

R. Pulveris cubebae ^iij. 

Copaibae ^iss. 

Aluminis gij. 

Sacchari albi ^j. 

Magnesiae ^iss. 

Olei cubebae, 

Olei gaultheriae, aa ^j. 
M. 

This mixture forms a paste, of which the patient may be directed 
to take a piece the size of a walnut, after each meal. The following 
prescription is particularly adapted to delicate stomachs : — 

R. Copaibae ^ij. 

Magnesiae £j. 

Olei menthae piperitae gtt. xx. 

Pulveris cubebae, 

Bismuthi subnitratis, aa, ^ij. 
M. 
To be divided into pills of five grains each, and coated with, sugar. 

R. Copaibae ^j. 

Magnesiae £ss. 

Pulveris cubebae ^iss. 

Ammoniae carbonatis ^ij. 

Ferri sulphatis ^j. 
M. (Me'ot.) 

To be divided into pills of five grains each : dose, three, three times a day. 

Copaiba and cubebs may also be obtained enveloped in capsules 
of gelatin, and this is a popular form of administration. The cap- 
sules obviate the disagreeable taste of these drugs, but they do not 
always prevent nausea and eructations, when their contents are sud- 
denly discharged into the stomach, by the solution of the envelope. 
In such cases, we may employ the French dragees which have been 
introduced within the last few years, and of which there are several 
varieties ; some containing copaiba alone, others cubebs, and others 
still both these drugs combined with iron ; I have found them all to 
be very reliable. The dose is from four to six, three times a day. 

Injections of an emulsion of copaiba into the rectum, in cases 
where it is not borne by the stomach, have been recommended, 
especially by Velpeau. I have never tried this method of adminis- 
tering copaiba, and should have but little faith in its efficacy. It is 
acknowledged that a much larger quantity must be used than when 
it is given by the mouth. A simple injection should first be 
employed to clear the rectum of fecal matter, when the following 
mixture may be thrown in : — 



COPAIBA AND CUBEBS. 95 

R. Copaibse ^v. 

Ovi vitelli No. j. 

Extracti opii gr. j. . 

Aquae ^viss. 
M. 

The nausea, eructations, and diarrhoea, which are often excited by 
copaiba, have already been referred to, and sometimes render it im- 
possible to administer this remedy in any form to a delicate stomach. 
The diarrhoea may often be controlled by the combination of alum 
or an opiate, but more frequently requires the drug to be suspended, 
and afterward resumed in smaller doses. 

Copaiba sometimes, also, gives rise to a cutaneous eruption, be- 
longing to the class of exanthemata, as roseola, erythema, or urti- 
caria. Such eruptions should be carefully distinguished from those 
of secondary syphilis, as may readily be done by the absence of 
coexisting syphilitic symptoms, by the itching that usually, but not 
always, attends them, and by their disappearance in a few days after 
the copaiba is suspended. The administration of copaiba should 
never be continued, if it produce this effect. 

Another unpleasant symptom not unfrequently occasioned bv 
copaiba, is pain in the region of the kidneys, dependent upon con- 
gestion of those organs. A few years ago, a patient was under my 
care for gonorrhoea, who had previously had several attacks of 
hematuria. Contrary to my advice, he took copaiba, which induced 
a return of the blood in his urine, and I afterwards learned that the 
administration of this drug had already produced a similar effect in 
a former attack of gonorrhoea. I always consider the presence of 
pain in the kidneys an indication that the copaiba should be omitted . 
for we have no right, in these days when renal disease is so common 
and a healthy kidney so rarely met with at a post-mortem examina- 
tion, to subject our patients to the risk of permanent injury. 

Cubebs may occasion, though much more rarely, any of the un- 
pleasant symptoms just mentioned as likely to occur from copaiba. 
Both of these drugs, in large doses, will, in rare instances, excite 
severe headache, giddiness, and even more serious symptoms con- 
nected with the nervous centres. Eicord mentions a case of tempo- 
rary hemiplegia, and another of violent convulsions, produced by 
copaiba ; in both instances, these serious symptoms were followed 
by the outbreak of a cutaneous eruption, also dependent on the 
drug. 

The anti-blennorrhagics now mentioned, are of undoubted efficacy 
in the treatment of many cases of gonorrhoea, but in others they 



96 URETHRAL GONORRHCEA IN THE MALE. 

utterly fail; nor have we any means of distinguishing these two 
classes of cases beforehand. As I have already stated, I think they 
hold a second rank to injections in the cure of this disease, and in 
much the larger proportion of the cases that come under my care, I 
have ceased to employ them at all. As a general rule, if they are 
likely to prove successful, their good effect will be apparent in a 
fortnight or three weeks from their commencement, and if, by this 
time, the disease continue unabated, they should be omitted, and 
other means employed to effect a cure. When long continued, they 
produce disorder of the digestive functions, impair the appetite, and 
induce general malaise and debility; a condition of the system 
highly calculated to prolong the duration of gonorrhoea. Though 
often of marked benefit, they are by no means indispensable in the 
treatment of every case of gonorrhoea. 

Preparations of the Gelseminum Sempervirens are much em- 
ployed at the South, given internally, in the treatment of gonor- 
rhoea; but in my hands have not proved of much benefit. This 
plant acts primarily on the nervous centres, and in full doses pro- 
duces staggering in the gait, dimness of sight, and double vision. 
In one of my patients who was taking it, the double vision was due 
to paralysis of the motor oculi of each eye, which passed off 
soon after the drug was suspended. The most convenient form for 
administration is Tilden's fluid extract, the dose of which is about 
fifteen drops three times a day, gradually increased until dimness of 
vision or staggering in the gait is perceived. 

Obstacles to Success. — A mistake, generally committed by patients 
who treat themselves for gonorrhoea and by some physicians, espe- 
cially in the early years of their practice, is over-medication and a 
neglect of the general health. Nothing is more common than to 
meet with a patient, suffering with gonorrhoea of several months' 
standing, who has been kept on low diet, and been taking various 
preparations of copaiba and cubebs, using a variety of injections 
often exceedingly irritant in their composition or strength, and who 
is now run down, weak in body and despairing in mind. His 
digestion is impaired, his appetite gone, and his clap as bad as ever. 
Let such a man lay aside his capsules, pills, powders, mixtures, and 
irritant injections; give him substantial food, and a tonic, as quinine 
or iron; limit the special treatment of his disease to a weak astrin- 
gent injection, as from one to three grains of acetate of zinc to the 
ounce of water, and his disease will probably begin to improve at 
once, and subside entirely in the course of a few days or weeks. 
Cinder any circumstances, you will have removed one great obstacle 



OBSTACLES TO SUCCESS. 97 

to a cure, and if the discharge do not entirely disappear, it is pro- 
bably kept up by some local complication, which can now be attacked 
with a prospect of success. The following is a type of this class of 
cases. 

Case. — P. A., aged 19, applied to me on May 5th, 1857, for a gon- 
orrhoea which he contracted about the middle of January. He had 
been under the care of several physicians, and had treated himself a 
portion of the time ; had taken copaiba in almost every form, and 
cubebs in large quantities ; and had used strong injections of nitrate 
of silver, sulphate of zinc, alum, and acetate of lead. He was now 
much debilitated, and complained of general malaise and loss of 
appetite, and the discharge was still copious. I passed a bougie to 
ascertain if he had stricture, but could discover none. I then directed 
him to abstain from all anti-blennorrhagics and to live well, and pre- 
scribed five grains of citrate of quinine and iron to be taken with 
each meal, and an injection of sulphate of zinc, three grains to the 
ounce. 

In one week from the time I first saw him, the discharge had dis- 
appeared. There was a slight return of it a few days afterward, 
which lasted only for a day or two, and did not again appear. 

In the large class of cases of which this is a type, the disease is 
kept up by a debilitated condition of the system, and requires for 
its removal general hygienic measures, and in most cases tonics. I 
have found the citrate of iron and quinine, and the tincture of the 
chloride of iron, most serviceable. 

Independently of debility, the chief causes of the continuance of 
a gonorrhceal discharge are the existence of stricture and irritation 
of the neck of the bladder. It is desirable in every obstinate case 
to ascertain if the former be present by the passage of a full-sized 
bougie, and if any obstruction be met with, appropriate treatment 
should at once be adopted ; but even in the absence of stricture, the 
introduction of an instrument into the Madder two or three times a 
week has a most beneficial effect upon old cases of clap. 1 

It sometimes happens that a case of gonorrhoea has been going 
on well for a week or ten days under the use of the anti-blennorrha- 
gics and injections — the discharge has almost entirely ceased, and 
the patient considers himself nearly well, when suddenly a relapse 
takes place; the discharge is once more thick and purulent; the 
scalding in making water returns ; the injection, which has scarcely 
been felt for a number of days, excites considerable pain, and at the 
same time the patient has a frequent desire to pass his urine, and 

1 See chapter on Gleet. 
7 



98 UEETHKAL GONORRHOEA IN THE MALE. 

suffers from an uneasy sensation in the perineal region. The latter 
symptoms denote that the disease has extended to the deeper portion 
of the urethra, and that there is irritation or inflammation of the 
neck of the bladder. Under these circumstances, the case requires 
to be very carefully watched and judiciously treated. Unless great 
care be used, the inflammation may extend through the vas deferens 
to the scrotal organs, and swelled testicle ensue; or the prostate 
gland may become involved. If irritant injections now be used, they 
will prove inefficient and will aggravate the symptoms. It is best 
to suspend the use of injections altogether, and to resort to the 
exhibition of alkalies and sedatives, as recommended in the inflam- 
matory stage, until the subsidence of the symptoms shall enable us 
to resume direct treatment; the patient should also be particularly 
careful with regard to exercise. Canada turpentine, the product of 
the Abies Balsamea, will also be found of essential service in these 
cases, in place of the anti-blennorrhagics, which should be omitted. 
It may be made into pills containing five grains each, of which from 
six to twelve should be taken daily. I have also been much pleased 
with the effect of tincture of ergot, administered in drachm doses 
three times a day. 

l\eatment of Special Symptoms. — It remains to speak of the treat- 
ment of certain special symptoms which may attend a case of gon- 
orrhoea, and one of the most annoying of these is chordee. Yarious 
sedatives are employed for the relief of this symptom, among which 
camphor holds the first rank. This may be given in the form of a 
pill, combined with extract of lettuce or opium, as in the following 
formulae : — 

R. Lactucarii, 

Pulveris camphorse, aa^ij. 
M. ft. pil. xx. 
Dose. — Two at bedtime. (Ricord.) 

R. Pulveris camphorse ^iss. 

Pulveris opii gr. x. 
M. ft. pil. No. x. 
Dose. — One or two. (Ricord.) 

Mr. Milton prefers camphor in a liquid form in large doses. He 
directs the patient to take one drachm of the tincture in water on 
going to bed, and every time he wakes up with chordee, to repeat 
the dose. He states that after the continuance of this treatment for 
two or three nights all tendency to chordee disappears. 

Lupulin is another remedy of undoubted power in allaying the 
excitability pf the genital organs, and possesses the advantage over 



TREATMENT OF SPECIAL SYMPTOMS. 99 

opium that it does not constipate the bowels. It may be given in 
doses of fifteen grains, triturated in a mortar with sugar. This 
quantity is to be taken before going to bed ; and may be repeated 
one or more times in the night if required. . 

Of the above means of relieving chordee, I regard Mr. Milton's 
method of giving camphor, if it do not disagree with the stomach, 
and the administration of lupuline, as the best; yet none of the 
remedies mentioned can be relied upon with certainty of ' producing 
the desired effect, for they all fail in many instances. Much may be 
accomplished by directing the patient to avoid eating or drinking 
for some hours before going to bed, to be careful to empty his blad- 
der and rectum, and to sleep on a hard mattress, with but few bed- 
clothes over him. The position in bed is also of importance, since 
erections are much less likely to take place when lying upon the 
side than upon the back. I have sometimes directed a suppository 
of hyoscyamus and belladonna to be introduced into the rectum 
with good effect. 

Another means of relief which I have found highly successful is 
bathing the genital organs in very hot water directly before going 
to bed. The reaction' after the application of heat has a sedative 
effect, and in this respect has exactly an opposite influence to that 
of the cold lotions which are sometimes advised. 

Hemorrhages from the urethra, occurring during erections, if 
slight, require no treatment. When copious, they are to be arrested 
by quiet, the horizontal posture, the application of ice externally, 
and the injection of ice- water into the canal ; and severe cases may 
require compression effected by the introduction of a bougie within 
the urethra, and a bandage around the penis, or a compress to the 
perineum. 

If abscesses form along the course of the urethra, they should be . 
opened at an early period, for fear that they may break internally, 
and thus give rise to urinary abscess and fistula. 

As an attack of gonorrhoea is passing off, it not unfrequently 
happens that the discharge assumes an intermittent character, 
entirely disappearing for a few days, and then, without apparent 
cause, reappearing for a day or two. This may occur several times 
in succession, and in some cases that I have witnessed, it has 
assumed great regularity. The surgeon should, of course, assure 
himself that the return of the symptoms is not due to imprudence, 
and, if satisfied of this, is generally safe in telling the patient that 
his disease will soon cease entirely to annoy him. 

It is important to continue treatment for some days after all traces 



100 URETHRAL GONORRHCEA IN THE MALE. 

of the disease have passed away, since relapses are very readily 
induced. They are usually brought on by the patient's neglecting 
the rules with regard to exercise, diet, etc., already laid down, or by 
his indulging in sexual intercourse. He should be particularly 
cautioned on these points, and should be directed to continue his 
medication, both external and internal, in decreasing doses, for at 
least ten days after the lips of the meatus have ceased to be glued 
together in the morning. Until every symptom of gonorrhoea has 
disappeared for this length of time, the patient cannot consider him- 
self as securely well, and should still be cautious in his habits for a 
fortnight longer. 

After the entire cessation of the discharge, patients sometimes 
complain of abnormal sensations in the genital organs, which they 
describe under the names of " tickling," " crawling," and sometimes 
" lancinating," and which may be nearly constant or intermittent at 
intervals of several hours or several days. These sensations, in most 
cases, are not dependent upon inflammation or organic changes in 
the part, but are of a strictly neuralgic character. They are best 
relieved by the passage of a full-sized sound every few days ; and 
they are much less felt when once the mind is set at rest with regard 
to any danger of a return of the gonorrhoea. 

The reader may be interested to know what is the average dura- 
tion of treatment required in the hands of the best surgeons for the 
cure of gonorrhoea, laying aside those cases which are seen in the 
first stage, and which are speedily cured by the abortive method. 
This may be estimated at three or 'four weeks. Greater success, on 
the average, is probably not attainable by any means with which 
we are at present acquainted. 



GLEET. 101 



CHAPTER II. 

GLEET. 

The term " Blennorrhea, " or, in common parlance, " Gleet," is 
applied to a slight and chronic discharge from the male urethra, 
unattended with symptoms of acute inflammation. 

Gleet generally follows without interval an attack of gonorrhoea, 
as a consequence of the neglect or unsuccessful treatment of the 
latter ; and, as the acute gradually subsides into the chronic disease, 
it is impossible clearly to define a line of demarcation between 
them, and to say when the former ceases and the latter begins. In 
many cases, however, gonorrhoea runs through its successive stages 
and is apparently cured ; when, after an interval of several weeKs 
or even months, the patient returns with the report that he has 
recently noticed in the morning on rising that the lips of his meatus 
adhere together, and, on separating them, that the urethra contains 
a small amount of matter ; he suffers no pain or inconvenience, but 
is still anxious about his discharge and desires to be free from it. 
In such instances, it is probable that the cure of the preceding 
urethritis was only apparent, and that a slight degree of inflamma- 
tion was left in the deeper portions of the canal, not manifesting 
itself externally until aggravated by some exciting cause, as coitus, 
alcoholic stimulants, fatigue, etc. Or, again, it is not improbable 
that there is a stricture of the urethra, which is the most frequent 
cause of the continuance of a gleety discharge following an acute 
attack of gonorrhoea. Other organic changes may exist within the 
canal and be productive of gleet, as vegetations similar to those met 
with upon the internal surface of the prepuce, and in rare instances, 
polypoid growths. 1 

Idiopathic gleet, or gleet not preceded by acute urethritis, mav be 
dependent upon various affections of the prostate, and especially 
upon the hypertrophy of this gland so common in old men. It may 
also arise from disorder of the digestive function, and from disease 

1 See Thompson on Stricture, p. 73 et seq. 



102 • GLEET. 

of the bladder or kidneys, whereby the urine is rendered abnor- 
mally irritant. 

Gleet is often maintained by a state of general debility, or by a 
strumous, rheumatic, or gouty diathesis. That general debility is 
a fruitful source of the persistence of gleet, is evident from the fre- 
quency of this disease in persons of broken-down constitutions, and 
from the beneficial influence of tonics and general hygienic mea- 
sures in its treatment. Again, gleet is peculiarly frequent and 
obstinate in persons of a strumous diathesis who are subject to 
chronic inflammation of other mucous membranes, and unde*r such 
circumstances is benefited by the administration of anti-strumous 
remedies. The influence of rheumatism and gout in the production 
of discharges from the urethra has already been mentioned in con- 
nection with gonorrhoea. 

Symptoms. — In many cases of gleet, the discharge is the only 
symptom. There is an entire absence of pain in the part, of redness 
and tumefaction of the lips of the meatus, and of scalding in passing 
water. In some instances, however, the patient experiences a feeling 
of uneasiness in the penis or perineum, or an itching about the 
glans or in the deeper portions of the canal, which may either be 
constant or attendant only upon the passage of the urine. Again, 
at the first act of micturition in the morning, the obstruction offered 
to the exit of the stream by the matter which has dried around the 
meatus and glued its lips together, often gives rise to forcible dis- 
tention of the canal, and a sharp momentary pain in the urethra, 
which may be avoided by previously separating the lips of the 
orifice. 

The discharge in gleet varies in its character, quantity, and in 
the time of its appearance. In some cases it is evidently purulent, 
especially when the gleet has followed a recent attack of gonor- 
rhoea. In other instances, it is perfectly transparent, and, examined 
under the microscope, is found to consist of a clear fluid,' containing 
epithelial cells and free nuclei, either with or without a few pus- 
globules. Again, coagulated masses, like the white of an egg, are 
sometimes forced from the canal. In some cases, the discharge is 
constant, and sufficiently copious to stain the linen; but in the 
majority it is perceptible only in the morning on rising. When 
dependent upon inflammation of the deeper portions of the canal, 
or of the prostate, it may only appear during the efforts of the 
patient at stool, or be mingled with the last drops of urine in mic- 
turition. The small amount of the discharge in most cases of gleet, 



SYMPTOMS — PATHOLOGY. 103 

and the frequency of this disease among soldiers, has given rise to 
the name "goutte militaire," employed by the French. 

The symptoms of gleet now described are liable to be aggravated 
by any cause which produces urethral or vesical irritation. In 
other words, a gleet is readily transformed into a clap. A hearty 
meal, alcoholic stimulants, free sexual indulgence, violent exercise, 
a long ride, or exposure to sudden changes of temperature, may 
bring on a copious purulent discharge, attended by tumefaction of 
the parts, scalding in micturition, and all the symptoms of acute 
gonorrhoea. Only a few hours are required for this change to take 
•place, and, hence, we may explain the sudden reappearance of some 
attacks of gonorrhoea — often supposed to be due to fresh contagion 
— when patients, too confident that they are well, are hasty in in- 
dulging in drink or coitus. 

Hunter, in his work on Venereal, states that " a gleet is perfectly 
innocent with respect to infection," and that in the relapses which 
so frequently occur, "the virus," in his opinion, "does not return." 
This statement, although often refuted, still finds place in many 
elementary works, which are in the hands of medical students. A 
doctrine more dangerous to the peace of families could scarcely be 
promulgated. It is, indeed, true, that men are occasionally met 
with who have for years suffered from gleet, and who have yet had 
frequent connection with their wives with impunity, but where con- 
tagion ceases and immunity begins, no one can tell ; and even if we 
were able to pronounce a discharge of a certain degree of purity 
innocuous, we could not foresee the effect upon it of a few hours' 
sexual indulgence. It may at the present moment be wholly 
mucous, and entirely innocent of contagious properties, and yet a 
short time hence be purulent, and in the highest degree dangerous. 
The fact is, no one can pronounce sexual congress safe, so long as a 
urethral discharge exists, and in replying to the frequent questions 
of patients on this point, the surgeon should not only avoid incurring 
the responsibility of allowing it, but do all in his power to dissuade 
from it. 

Pathology. — Our knowledge of the pathology of gleet is some- 
what imperfect, since the urethra is beyond the reach of direct 
observation, and opportunities for making post-mortem examina- 
tions of persons affected with this disease are very rare. There can 
be no doubt, however, of the general truth of the law that, while 
the straight or anterior portion of the urethra is affected in gonor- 
rhoea, the posterior and curved portion is the most frequent seat of 



104 GLEET. 

gleet, as evinced by the extension of the inflammation in many 
cases to the testicle, the uncomfortable sensations experienced by 
the patient in the perineum, and the difficulty of curing the disease 
by meaus of injections, unless the fluid be made to enter the deeper 
portions of the canal ; moreover, after the spongy urethra has been 
freed of its discharge by pressure along the under surface of the 
penis, an additional quantity may generally be forced out from the 
bulbous and membranous portions by pressure upon the perineum. 

In the few post-mortem examinations which have been made of 
persons affected with urethral discharges, sufficient attention has not 
been paid to the duration of the disease nor to the symptoms during " 
life. The most minute description of the pathological appearances 
of gonorrhoea and gleet is the one given by Eokitansky, who says : 
" We find the anatomical characters to be those belonging to catarrh 
generally ; in the acute stage there is, according to the violence of 
the process, redness, injection, tumefaction of the urethral mucous 
membrane, or secretion of puriform mucus; in the chronic stage 
there is tumefaction of the mucous membrane, enlargement of the 
follicles, relaxation of the sinuses, and a white or colorless secretion. 
The inflammation is either uniformly diffused over the urethra, or 
is limited to one or more spots. The latter is especially the case in 
genuine gonorrhoea of the male urethra ; we here find not only the 
navicular fossa, but every point as far as the prostatic portion, and 
especially the vicinity of the bulb of the urethra liable to become 
the seat of the disease. When the gonorrhoea is very violent and 
obstinate, a small tubercular swelling, which results from the depo- 
sition of fibrous matter in the spongy tissue of the urethra, is found 
at these points." 1 

Mr. Thompson has found nearly the same appearances : " Observa- 
tion demonstrates that the two spots which suffer most from gonor- 
rhoeal inflammation, are the fossa navicularis and the bulb ; I have 
had opportunities of observing this two or three times in the dead- 
house, on the bodies of patients who had been suffering from 
gonorrhoea shortly before death. Unusual vascularity is found in 
the latter situation, particularly if the affection have been chronic, 
while the intermediate part appears comparatively very little af- 
fected. There is a preparation in the Museum of St. George's 
Hospital/, which exhibits the urethra of a patient who died while 
suffering from gonorrhoea, in which an ulcer exists (the only one to 
be seen) in the commencement of the membranous portion." 2 It is 

* Pathological Anatomy, Sydenham Society's Translation, vol. ii., p. 233. 
» Stricture of the Urethra, p. 84. 



TREATMENT. 105 

impossible to determine whether the ulcer in the case referred to by 
Mr. Thompson was a chancroid or chancre, or a superficial erosion 
such as is met with in balanitis ; it was probably one of the former, 
since gonorrhceal inflammation rarely produces ulcerations involv- 
ing the whole thickness of the mucous membrane and capable of 
detection in a preparation that has been preserved' for a long time 
in spirit. 

The lacuna magna upon the superior wall of the fossa navicularis 
is probably, in some instances, the source of the discharge in gleet, 
since it is peculiarly exposed from its situation to participate in the 
inflammation of gonorrhoea, and its internal surface is not readily 
accessible to injections. Dr. Phillips states that he has succeeded 
in curing four obstinate cases of gleet by introducing a director 
along the upper surface of the urethra until its extremity entered 
the lacuna magna, and slitting up the wall of the follicle with a 
narrow bistoury. 

When the disease is situated in the deeper portions of the canal, 
we may sometimes determine its seat by the introduction of a 
buibous pointed sound or bougie. The patient flinches when the 
affected part of the canal is reached, and the enlarged extremity of 
the instrument meets with slight obstruction from the thickened 
mucous membrane. 

It appears, therefore, that the pathological changes of gleet are 
similar to those met with in chronic inflammation of other mucous 
membranes, as the conjunctiva, tear passages, and the external 
meatus auditorius, and the extension of the inflammatory process 
to the membrane lining the follicles and the ducts which open into 
the deeper portions of the urethra, may account for the well-known 
persistency of the disease, which is almost proverbial. 

Treatment. — The treatment of gleet should be addressed to the 
general condition of the patient as well as to the local disease. It 
may be laid down as a rule to which there are but few exceptions, 
that in gleet the tone of the general health is more or less reduced. 
Not that all patients with gleet are necessarily weak and emaciated ; 
on the contrary, many appear to be robust and hearty; but it is 
almost always the case that they are not capable of the same amount 
of exertion as formerly ; they are sensible that they have lost a 
portion of their animal vigor ; and the benefit of general hygienic 
measures and tonics in their treatment is unmistakable. The diet 
should be plain but substantial, consisting of fresh meat, vegetables, 
eggs, etc., to the exclusion of salt meats, cheese, and highly-seasoned 



106 GLEET. 

articles ; and secretion from the skin should be promoted by means 
of frequent sponging or bathing. With regard to exercise, although 
a long walk or ride, especially when carried to fatigue, will be found 
to aggravate the discharge, yet when commenced with moderation, 
and gradually and steadily increased in proportion to the strength, 
it is found to be highly beneficial. Healthy exercise of the mind 
is no less important than that of the body, and the attention of the 
patient should be distracted as much as possible from his disease, 
and all books and associations calculated to excite the passions be 
avoided. The bowels should be opened daily, if possible by select- 
ing such articles of food as are laxative, and by regularity in the 
hour of going to the closet, or, if required, by the administration of 
medicine. One of the following pills taken at bedtime, will usually 
insure a free stool in the morning. 

R. Strychniae gr. ss. 

Pil. colocynth. comp. gss. 

* M. 

Divide into thirty pills. 

In the tincture of the chloride of iron, we have a most valuable 
combination of a tonic and an astringent ; which, in most cases of 
disease of the generative organs in the male and female, is unequalled 
by any of the more modern and elegant preparations of this mineral. 
It may be given in doses of from five to twenty drops, largely 
diluted with water, three times a day, directly after meals. If the 
dose be properly graduated, it less frequently excites headache in 
the male than the female ; should this unpleasant symptom occur, 
iron reduced by hydrogen may be substituted for it, in doses of 
three grains, three times a day. Where the constitutional debility 
is marked, the union of quinine with iron may be desirable, as in 
the following : — 

R. Ferri et quiniae citratis 3J-ij. 

Aquae gj. 

Syrupi limonis §ij. 
M. 
A teaspoonful after each meal. 

R. Tincturce cantharidis gj. 

Quinise sulphatis £ss. 

Tincturae ferri chloridi gij. 

Acidi sulphurici dilutigtt. xxx. 

Aquae destillatae 5viij. 
M. 
One ounce three times a day. (Childs.) 

Other salts of iron, as the tartrate of iron and potassa, or the pyro- 
phosphate of iron, may be substituted for the citrate, in the first of 
the aoove prescriptions. 



TREATMENT. 107 

In the administration of iron I have always found a rule laid 
down by Trousseau, a good one, viz., not to stop the medicine sud- 
denly ; after the object for which it is administered has been attained, 
it may be omitted for a fortnight, when it should again be resumed 
for a few weeks ; in this way its effect is rendered much more per- 
manent. 

With patients of a strumous diathesis, cod-liver oil, the syrup of 
the phosphates, or Blancard's pills of iodide of iron, may often be 
used with advantage. I have found that the iodide of potassium 
has a tendency to increase the discharge from the urethra, as it often 
does the secretion from other mucous membranes, and I do not there- 
fore administer it. This effect of the iodide may frequently be 
observed, when we are giving it for tertiary syphilis to patients, who, 
at the same time, are affected with gleet. 

From what has already been said of copaiba and cubebs, it is evi- 
dent that but little good can be expected from their administration 
in cases of chronic urethral discharge. Moreover, most patients 
whose disease has arrived at this stage, have already taken them ad 
nauseam for the preceding gonorrhoea ; hence, we are rarely called 
upon to administer them in pure gleet. In those cases, however, in 
which the gleet has relapsed into a clap, they may be given with 
benefit, especially when combined with a tonic, as in the dragees of 
copaiba, cubebs, and citrate of iron ; in Meot's pills, the formula for 
which has already been given; and as in the following prescrip- 
tion : — ■ 

R. Copaibse !§ss. 

Tincturee cantharidis 5SS. 
Tincturee ferri chloridi ^j. 
M. 

Dose. — Thirty drops three times a day. 

The reader will observe that the tincture of cantharides is an 
ingredient of several of the above prescriptions. Experience has 
shown that this drug exerts a decidedly curative action in many 
cases of gleet, and in gonorrhoea also, in the chronic stage. It is a 
favorite remedy with the homoeopaths, in doses of a drop of the tinc- 
ture every few hours, in the acute stage of clap, and is considered by 
them to be indicated by scalding in micturition, chordee, and a green- 
ish or bloody discharge. I have used it, however, only in the chro- 
nic stage. The tincture may be given in doses of three or five drops 
three times a day, or it may be combined with iron, as follows : — 

R. Tincturse cantharidis ^ij. 

Tincturse ferri chloridi ^vj. 
M. 
Ten drops in water, three 'times a day. 



108 BOUGIES. 

In some cases of gleet there is considerable irritability of the neck 
of the bladder, as shown by a frequent desire to pass the urine and 
unpleasant sensations in the perineum. In these cases benefit will 
be derived from the administration of the salts of potash, combined 
with hyoscyamus, as in the prescriptions already given when speak- 
ing of the acute stage of gonorrhoea. Wine of ergot is also an 
excellent remedy under these circumstances. 

Bougies. — In all cases of gleet, the urethra should be carefully 
examined with a full-sized bougie or sound, in order to detect the 
presence of stricture ; and if the slightest contraction be discovered, 
it should at once receive appropriate treatment, since upon its 
removal will probably depend the cure of the discharge. Dr. Charles 
Phillips, whose name is little known to the American public, but 
who in Paris has acquired an enviable reputation in diseases of the 
genito-urinary organs, states that gleet is almost invariably depend- 
ent upon slight stricture, which may be detected by means of bul- 
bous-pointed and knotted bougies, but which is frequently over- 
looked from the want of careful exploration with proper instruments. 1 

"Whatever may be the truth of this statement, which, to say the 
least, requires confirmation, the frequent passage and retention of 
bougies is one of the best means known for the treatment of gleet, 
even when no stricture can be discovered by the ordinary mode of 
examination. The manner in which bougies effect a cure of chronic 
urethral discharges is somewhat obscure, but is probably to be ex- 
plained on the ground that they distend the canal, expose lacunae in 
which matter would otherwise lodge, and separate for a time the dis- 
eased surfaces ; or, again, they may serve to stimulate the vessels of 
the part, and thus change their action. 

Bougies tapering towards the extremity and terminating in an 
olive-shaped point, are well adapted for the purpose. They are 
introduced easily and with little inconvenience to the patient, and 
the contraction near their point facilitates the introduction of medi- 
cated ointments into the deeper portions of the canal. The instru- 
ment should be large enough fully to distend the canal but not to 
stretch it, and should be smeared with cerate, lard, olive or castor 
oil, or glycerin. The bladder should previously be emptied and the 
patient placed in the recumbent posture. However gently it may 
be introduced, the first passage of a bougie usually excites a more 
or less disagreeable sensation, which sometimes gives rise to syncope, 
and which generally renders it advisable to withdraw the instrument 

1 Traits ties Maladies des Voies Urinaires, Paris, 1850, p. 32. 



BOUGIES. 109 

m a few minutes ; but after two or three insertions it ceases to give 
annoyance, and may be retained for half an hour or an hour. 

It sometimes happens that the bougie aggravates the discharge, 
and revives the acute inflammation which has for a time disap- 
peared. In such cases it is best to suspend the treatment and resort 
to injections, which will often effect a permanent cure. This aggra- 
vation of the symptoms, however, according to my experience, takes 
place in a minority of cases only. 

With this exception, the passage of the bougie may be repeated 
every second or third day at first, and afterwards every day, or in 
some instances as often as twice a day. The length of time requi- 
site for a cure by means of bougies varies in different cases. As 
examples of their successful employment I may mention one case 
recently under my care, a gleet of four years standing, which was 
treated with the tincture of the chloride of iron internally, and the 
introduction of bougies every second day, and in which a cure was 
effected in two weeks. In another case, a gleet of nine months, the 
discharge disappeared in three weeks under the use of the same 
means. Other cases of a like character might be mentioned, but 
such satisfactory results cannot by any means be expected in every 
instance. In many, this treatment must be continued for several 
months, or other measures, as injections and blisters, be resorted to. 

Bougies may be medicated in various ways. Calomel rubbed up 
with sufficient glycerin or oil to cover it, forms a very cleanly and 
excellent mixture with which to anoint the bougie, and I think 
materially assists the curative action. Mercurial ointment may also 
be used, either alone or combined with extract of belladonna, the 
latter being added in case the urethra is irritable. 

R. Unguenti hydrargyri :§ss.. 

Extract! belladonna gss. 
M. 

For the purpose of stimulating the mucous membrane, we may 
employ the diluted ointment of red oxide of mercury, or an oint- 
ment containing a few grains of nitrate of silver, but such applica- 
tions should not be continued for any length of time, lest they keep 
up the discharge. 

R. Ung. hydrarg. oxidi rubri gj. 

Adipis giij. 
M. 

R. Argenti nitratis gr. v-x. 

Adipis gj. 
M. 



110 GLEET. 

Injections. — Injections have been so fully discussed in the preced- 
ing chapter, that little remains at present to be said of their compo- 
sition, or' the ordinary mode of their administration. 

In gleet as in gonorrhoea, weak solutions of the sulphate or ace- 
tate of zinc (containing from two to three grains to the ounce of 
water) are in most instances to be preferred; and the injection 
should be made to permeate the urethra as deeply as possible, in 
order that it may be applied to the whole extent of the affected 
surface, but care should be taken not to distend the canal with too 
much force, the sensations of the patient being the best indication 
when a sufficient amount has been employed. So far as inflamma- 
tion of the testicle and prostate have any connection with the use 
of injections, I believe they are more frequently, due to violent 
manipulation than to the irritant character or strength of the solu- 
tion. Hence, injections should always be used with gentleness, 
while at the same time the canal should be entirely filled, that none 
of the folds into which the urethral walls are naturally thrown except 
during the passage of the urine, may escape coming in contact with 
the astringent fluid. With this precaution, a weak injection may 
be employed to advantage every two or three hours; a degree of 
frequency which will often prove successful when a less degree has 
failed. 

In addition to the formulae for injections given in the chapter 
upon gonorrhoea, the following may be added : — 

R. Hydrargyri bichloridi gr. j. 

Aquae ^viij-xij. 
M. 

R. Gallae gj. 

Aluminis ^ij. 
' , Aquae ^viij. 
M. 

R. Acidi nitrici gtt. xvj-xl. 
Aquae ^viij. 

I have recently employed with very satisfactory results the solu- 
tion of persulphate of iron prepared by Dr. Squibb, as in the fol- 
lowing : — 

R. Liq. ferri persulphatis (Squibb) £ss. 

Aquae ^vj. 
M. . 

The strength of the above solution may, in some instances, be 
increased. 

Kicord advises solutions containing iodine in scrofulous subjects, 



INJECTIONS. Ill 

a ad although the injection of this mineral into the urethra cannot 
be supposed to affect the constitutional diathesis, yet it may exert a 
beneficial action upon the mucous membrane as when applied to the 
fauces. 

R. Tinct. iodinii gtt. viij. 

Aquae 3 viij. * 

M. (Ricord.) 

R. Ferri iodidi gr. viij. 

Aquae ^viij. 
M. (Ricord.) 

I will here repeat a suggestion previously given, that the use of 
any medicated injection, and especially one containing insoluble 
ingredients, will prevent even a sound urethra from "exhibiting its 
normal dryness. Without due caution, therefore, a patient may go 
on injecting long after his disease is cured. Hence, after the dis- 
charge has for some time been reduced to a very minute quantity, 
and especially if it appear to consist of little more than the inso- 
luble deposit of the solution, the injection should be omitted for a 
few days, in order that the exact condition of the urethra may be 
determined; or, again, it may be administered only once in the 
twenty-four hours, selecting for the purpose the early part of the 
day, and the appearance of the meatus the following morning will 
indicate what progress has been made towards a cure. 

Substitutive medication is sometimes employed in gleet as in the 
abortive treatment of the first stage of gonorrhoea. Thus, highly 
irritant or caustic injections are used with the intention of exciting 
acute inflammation, upon the subsidence of which the chronic 
affection may perhaps disappear. Nature accomplishes the same 
result in the same manner, when, as sometimes happens, after the 
cure of a fresh attack of gonorrhoea no traces remain of a preceding 
gleet. Substitutive treatment, however, is less successful in gleet 
than in the early stage of gonorrhoea, since the seat of the disease 
is less accessible and the mucous membrane more deeply affected , 
moreover, it is less safe, since an irritant injection extended to the 
deeper portions of the canal is more liable to induce swelled testicle 
than when limited to the fossa navicularis. 

Either nitrate of silver or chloride of zinc is most frequently 
employed in the substitutive treatment of gleet, and, as in the 
abortive treatment of gonorrhoea, the solution may be a strong one 
and injected but once, or weak and repeated a number of times. 
For instance, the surgeon may thoroughly and once for all inject 
with his own hands a solution of ten or fifteen grains of nitrate of 



112 GLEET. 

silver, or five grains of the chloride. of zinc to the ounce of water; 
or a weaker solution of either (from one to five grains of the nitrate, 
and from half a grain to two grains of the chloride) may be injected 
by the patient several times a day until the discharge becomes 
copious and purulent, when the injections should be suspended 
until -their effect upon the gleet can be determined. 

Sometimes, as previously stated, the pain excited in a certain 
portion of the urethra by a bulbous pointed bougie and the slight 
obstruction presented by the thickened mucous membrane, will 
indicate the probable source of a gleety discharge ; and in such 
instances, having first measured its distance from the meatus, the 
affected surface may be cauterized with Lallemand's porte-caustique. 

Deep Urethral Injections. — In the ordinary method of injecting 
the male urethra, it is impossible to make the fluid pass through 
the whole extent of the canal into the bladder. After a certain 
portion (about half an ounce) of the contents of the syringe has 
been injected, the remainder escapes above the piston, or, however 
tightly the glans may be compressed around the point of the instru- 
ment, flows from the meatus. The obstruction to the entrance of 
the fluid is due to the contraction of muscular fibres (the compressor 
urethras muscle) which surround the membranous portion and serve 
as a sphincter to the urinary canal ; 1 and this is the posterior limit 
of the application of the fluid to the urethral walls by the more 
common method of injecting. In order to reach the deeper portions 
of the canal, which are involved in many cases of gleet, it becomes 
necessary to resort to injections through a catheter, or by means of 
the " urethral syringe with extra long pipe," manufactured by the 
American Hard Eubber Company, or with Tiemann's "universal 
syringe," which is provided with a catheter extremity. 2 

The length of the urethra should be measured by introducing the 
catheter and marking the point in contact with the meatus when 
the urine first commences to flow; upon withdrawing the instru- 
ment the distance between its eye and the mark upon the stem will 
be the measurement required. On again introducing the catheter 
for the purpose of injecting (the patient having first passed his 
water), it is an easy matter to carry its point within half an inch of 
the vesical neck without entering the bladder, when the fluid may 
be thrown in by means of a syringe as the instrument is slowly 

1 See the section on the Anatomy of the Urethra in the chapter on Stricture. 

2 This instrument will be found very useful in the treatment of venereal diseases, 
for instance in aeep urethral injections, in injections into the nostrils and pharynx, 
etc. 



DEEP URETHEAL INJECTIONS. 



118 




Fig. 1. 




=L M- 



00 



Tiemann's " Universal Syringe." 



withdrawn. If the catheter be sufficiently large to moderately dis- 
tend the canal, none of the injection will escape from the meatus so 
long as the eye of the instrument is in the prostatic or membranous 
portion of the urethra, since the contraction of the same muscle 
which prevents the entrance of fluid from without, also prevents its 
exit from within, and obliges it to flow backwards towards the 
bladder ; hence we may, if we choose, limit the application of the 
injected fluid to the deeper portions of the canal exclusively, and 
the pain excited will be found to be less than when a solution of 
the same strength is thrown into the external portion, since the 
urethra, like other mucous passages, is most sensitive near its outlet. 
The chief disagreeable sensation following an injection thus con- 
fined to the portion of the urethra lying between the compressor 
urethrae muscle and the neck of the bladder, is an urgent desire to 
pass water, which, however, should be resisted as long as possible, 
that the fluid may have time to act upon the urethral walls before 
it is washed away or neutralized by the urine. During the succeed- 
ing twenty -four hours, micturition is somewhat more frequent than 
usual,' but is not particularly painful ; and the discharge is often 
slightly increased for a day or two. 

The efficacy and safety of these injections in affections of the 
deeper- seated portions of the urethra is attested by MM. Diday 1 and 

1 Des Injections Circonscrites a laPartie Profonde de l'Uretre, de leur Mode d'Exe"- 
cution, et de leur Efficacite Curative ; Annuaire de la Syphilis, anne*e 1858, p. 61. 
Diday's method of employing deep urethral injections has been followed in the above 
description. 

b 



'Ill GLEET. 

Bonnet, of Lyons, Mr. Langston Parker/ of Birmingham, and my 
own experience.. The same formulas may be employed that have 
been recommended for injections by the more common method, and 
the application may be repeated once or twice a week. 

Blisters. — Blisters were long ago recommended for the cure of 
obstinate cases of gleet, but had almost fallen into disuse, when they 
were revived by Mr. Milton, in his work on the treatment of gonor- 
rhoea. This author speaks of them in the following terms: "I have 
seen two blisters, with a mild injection or two, at once cure a clap 
which had defied the most energetic treatment; and as I never found 
a case which resisted blistering and injections together, that was not com- 
plicated with stricture or affection of the testicle, I am slowly arriving 
at the conviction, that every case of clap or gleet, however obstinate, may, 
if uncomplicated, be cured by blistering, singly or combined." 2 It is to 
be feared, however, that this remedy has proved less successful in 
the hands of other surgeons than in Mr. Milton's. Eecent writers 
who have spoken favorably of it, appear to have done so chiefly on 
Mr. Milton's authority ; others, as Mr. Langston Parker, have given 
their testimony decidedly against it, and in my own practice it has 
not been attended with such success as to lead me to prefer it to 
other and less disagreeable modes of treatment. Still it may be 
worthy of a trial in 'obstinate cases which have resisted the use of 
bougies and injections. 

The manner of applying blisters to this region is of considerable 
importance. The hair should be shortened around the root of the 
penis, and a piece of paper be wrapped around the organ, and cut 
in such a manner as to form a pattern of ijs surface from the pubis 
to within half an inch of its extremity. The blister, corresponding 
in shape and size to the pattern, should be applied to the penis, and 
tied or fastened in its place, that it may not slip, and, coming in con- 
tact with the scrotum, produce a troublesome sore. It should not 
be retained longer than two hours, during which the patient must 
remain quiet. The morning is the best time for its application, 
since, if applied at night, it is likely to prevent sleep. On removing 
it, the surface is found to be reddened, but not vesicated, unless, 
perhaps, at a few points ; and the penis should new be covered with 
a rag spread with simple cerate, and be protected from friction by 
an external layer of cotton wadding. 

1 Syphilitic diseases, p. 82. Mr. Parker injects the fluid into the bladder, lets it 
remain for a few minutes, and desires the patient to force it out. This method is 
not so good as the one above recommended. 

2 Milton on Gonorrhoea, p. 90. The Italics are in the original. 



SEPARATION OF THE AFFECTED SURFACES. 115 

On examining the parts after a few hours, it will be found that 
numerous bullae have formed on the surface, which at first appeared 
to be only reddened. These may be pricked, and the serum which 
they contain evacuated, but the epidermis should be carefully pre- 
served. I have sometimes found the extremity of the prepuce be- 
yond the site of the blister, puffed out with an effusion into its 
cellular tissue, which may be left to take care of itself, or, if exces- 
sive, be evacuated by a few punctures with a lancet. 

Cantharidal collodion is a more convenient application than the 
unguentum lyttse, but its effect cannot be limited like that of the 
latter, which should therefore be preferred. When applied for a 
few hours only, I can confirm Mr. Milton's statement, that blisters 
do not excite severe pain, nor produce a troublesome sore. The first 
effect of their application is to increase the urethral discharge, which 
can only be expected to be benefited in the course of five or six 
days. The blister may be repeated at the end of a week, if any 
discharge still remain. The perineum may be blistered in a similar 
manner, but this will require the patient to be kept in bed until the 
vesicated surface has healed. 

Separation of the Affected Surfaces. — Contact of the diseased sur- 
faces doubtless assists in keeping up the discharge in gleet, as it is 
well known to do in balanitis. Hence it has been proposed, by 
means of a probe and a gum-elastic bougie open at the extremity, 
to introduce a strip of lint, either dry or soaked in some astringent 
fluid, within the urethra, and thus maintain its walls apart, renewing 
the application after each passage of the urine. This method, in 
which I have had no experience, has been successful in some in- 
stances, but is very troublesome and inconvenient, and would appear 
to be attended with danger of the lint slipping entirely into the 
urethra, and entering the bladder. Civiale mentions a case in which 
this accident occurred, but does not give the ultimate result. 1 Mr. 
Milton 2 states that it has happened to him in several instances, and 
that the lint has always found its own way out, but the danger of its 
retention is too great to be incurred. Separation of the affected sur- 
faces is partially effected by certain forms of injections, as those 
containing bismuth, calamine, and other insoluble ingredients. 

Finally, in obstinate cases of gleet in which the discharge appears 
to come from the anterior portion of the urethra, laying open the 
lacuna magna, as recommended by Dr. Phillips, is worthy of a trial. 3 

1 Maladies des Organes Genito-urinaires, vol. i. p. 444. 

2 On Gonorrhoea, p. 31. 

3 See page 105. 



116 BALANITIS — CAUSES. 



CHAPTER III. 

BALANITIS. 

If the prepuce be retracted, a mucous surface of considerable 
extent is exposed, a portion of which covers the glans penis, and the 
remainder consists of the internal reflection of the prepuce. This 
surface may be the seat of inflammation, similar to that which has 
been described as affecting the urethra. If the disease be confined, 
as it sometimes is, to the membrane covering the glans, it should, 
strictly speaking, be called balanitis ; if to the internal surface of the 
prepuce, posthitis, and if it involve both, balano-posthitis ; all these 
varieties, however, for the sake of convenience, are commonly in- 
cluded under the one name, balanitis. Gonorrhoea spuria, balano- 
preputial gonorrhoea and external blennorrhagia are other terms by 
which it is sometimes known. 

Causes. — Men in whom the prepuce is very long, or who are 
affected with congenital phymosis, are peculiarly exposed to bala- 
nitis, since the mucous membrane covering the glans, and lining the ' 
prepuce, is maintained in so sensitive a condition, from its want of 
exposure to the air and friction, that inflammation is readily set up 
by the least cause of irritation. In persons with congenital phy- 
mosis, the mere collection of sebaceous matter, the removal of which 
is prevented by the occlusion of the preputial orifice, is sufficient to 
give rise to balanitis; and I have known of several instances in 
which, from inattention, the discharge was supposed to come from 
the urethra, and was mistaken for gonorrhoea. The diagnosis can 
readily be made by exposing and wiping the meatus, and then 
observing whether upon pressure the matter comes from the urethra 
or the balano-preputial fold. Moreover, the pain in micturition 
extends along the course of the canal, while in balanitis it is less 
severe and confined to the extremity of the penis. 

In general, the exciting causes of balanitis are the same as those 
of urethral gonorrhoea. Thus it may arise from exposure to °-onor- 
rhoeal or leucorrhoeal discharges, or from intercourse about the time 



SYMPTOMS — TREATMENT. 117 

of the menstrual period ; and, even more frequently than gonorrhoea, 
from coitus with a healthy woman, particularly under circumstances 
of special excitement, from violence, masturbation, excessive exer- 
cise, the want of cleanliness, errors in diet, and atmospheric in- 
fluences. To these should also be added the presence of a chancroid, 
chancre, or an eruption dependent upon syphilis or other causes, 
upon the mucous membrane of the glans or prepuce. 

Symptoms. — The symptoms of balanitis are tenderness of the 
extremity of the penis, an itching sensation beneath the prepuce, 
and scalding during micturition if the urine comes in contact with 
the affected surface. The inflamed mucous membrane is sensitive 
on pressure, reddened, and often denuded of epithelium in irregular 
patches, which are of a darker red than the surrounding surface 
where the epithelium is but partially detached. These superficial 
excoriations are generally multiple, and are similar to the ulcera- 
tions frequently met with upon the cervix uteri. The affected 
surface secretes a muco-purulent fluid, varying in quantity and 
consistency, as in gonorrhoea. If phymosis exist and the preputial 
orifice be so contracted as not to afford free exit to the discharge, 
the matter may collect at the base of the glans and form an abscess. 
An effusion of serum takes place in the cellular tissue of the pre- 
puce, rendering it more or less oedematous, and sometimes occasion- 
ing accidental phymosis. The general system sympathizes but little 
with the local affection, which is in most cases of short duration, 
and very amenable to treatment. The inguinal ganglia may, in 
rare instances, become slightly enlarged and sensitive, but they 
never suppurate. 

One attack of balanitis predisposes to another. Men with a long 
prepuce or congenital phymosis, are often met with who have lived 
thirty or forty years without suffering inconvenience from their 
malformation, but who, after one attack of balanitis, are constantly 
subject to others, following intercourse with the most healthy woman, 
or even mere imprudence in diet. 

Treatment. — "When the prepuce can be retracted, the treatment 
of balanitis is exceedingly simple. All that is necessary, in most 
cases, is to free the parts from any collection of matter by gently 
washing them with tepid water, and then to cut a piece of lint or 
soft linen into pieces about an inch square, and laying them upon 
the glans with their upper margin well up in the furrow behind the 
corona, to draw the prepuce over them. In this manner the inflamed 



118 BALANITIS. 

surfaces are isolated from each other, and speedily take on a more 
healthy action. The frequency with which this application should 
be repeated depends upon the copiousness of the discharge ; gene- 
rally from two to four times in the twenty-four hours is sufficient, 
and a cure is usually attained in a few days or a week. In severe 
cases, however, other measures than those mentioned may be desira- 
ble. If the surface be excoriated, it is well to pencil it over lightly 
with a crayon of nitrate of silver, or to apply a solution of this salt, 
of the strength of a drachm to the ounce of water. Again, instead 
of using the lint dry, it may be moistened in either of the following 
mixtures : — 

R. Liquoris plumbi diacetatis 3J. R. Liquoris sodas chlorinatse giij. 

Aquae ^ij. - Aquas 3 v. 

M. M. 

R. Acidi tannici gj. R. Extracti opii ^j. 

Glycerin ^j. Zinci sulphatis gr. vj. 

M. • Glycerin §j 

Aquse 31J. 
M. 

When phymosis, either congenital or acquired, exists, the parts 
are less accessible to treatment. In this case the nozzle of a syringe 
holding several ounces and rilled with tepid water, should gently be 
inserted between the glans and prepuce, and its contents be dis- 
charged into this cavity, in order to free it from all collection of 
matter. A few drachms of a solution of nitrate of silver, or of one 
of the lotions just mentioned, may then be thrown up, and this 
should be repeated several times in the course of the day. In these 
cases, Mr. Langston Parker highly recommends the following pre- 
paration, introduced between the glans and prepuce by means of a 
camel's hair pencil : — 

R. Cerati simplicis, vel mellis, 

Olei olivae, aa ^j. 

Hydrargyri chloridi gss. 

Extracti opii gj. 
M. 

If the balanitis be attended by much infiltration into the cellular 
tissue of the prepuce, the fluid should be evacuated by several 
punctures with a lancet. If the patient can keep his bed, the penis 
may also be enveloped in a single thickness of linen, wet with cold 
water or diluted Goulard's extract, and exposed to the air. If, how- 
ever, he continues his daily occupation, no benefit can be expected 
from such applications, which, when confined by the clothes, act 
like poultices, and favor rather than prevent oedema. In all cases 



TKEATMENT. 119 

the cure of balanitis will be accelerated, if the patient be kept quiet 
and the parts elevated. When this disease is dependent upon the 
presence of an ulcer, secondary eruptions or vegetations, these should 
receive their appropriate treatment. 

With persons who have repeated attacks of balanitis it becomes 
an important object to take measures to prevent them. To accom- 
plish this the strictest cleanliness should be enjoined. The parts 
should twice a day be cleansed of all accumulation of their natural 
secretion, and afterwards moistened with an astringent lotion, as a 
mixture of equal parts of brandy and water with the addition of 
alum, a solution of tannin, or any of the astringent washes already 
mentioned. It is also desirable to attend to the digestive functions, 
and to regulate the diet. The influence of a long prepuce in pro- 
ducing relapses of this disease has already been referred to. I have 
sometimes succeeded in remedying this malformation by directing 
the patient to keep his prepuce constantly retracted by means of a 
narrow bandage applied around the penis, posterior to the glans. 
If this be worn for a few weeks, the prepuce will often remain re- 
tracted without further assistance, and the mucous surface of the 
glans becomes hardened by exposure and friction. If this attempt 
prove unsuccessful, the superfluous integument should be removed 
by circumcision. 



120 PHYMOSIS. 



CHAPTER IV. 

PHYMOSIS. 

The term Phymosis is applied to that condition of the penis in 
which it is impossible to retract the prepuce behind the glans. 

In the majority of cases phymosis is a congenital malformation 
due to unnatural narrowness of the preputial orifice, and may be 
associated with adhesions, varying in position and extent between 
the glans and its covering. A remarkable instance of this kind is 
recorded in the Surgical Register of the N. Y. Hospital: Joseph 
Smith, of Prussia, aged 49, was admitted into this institution Oct. 
19, 1832, with congenital phymosis. Dr. Stevens removed the free 
portion of the prepuce, which was found to be attached to the margin 
of the meatus instead of the base of the glans, and formed a tubular 
prolongation of the urethra nearly an inch in length. 

Congenital phymosis is a source not only of great inconvenience 
to the subject of it, but of increased exposure to venereal diseases 
in promiscuous intercourse, and is sometimes the cause of serious 
disturbance in the genito-urinary and nervous systems. 

Mr. Jonathan Hutchinson 1 has shown by statistics that syphilis is 
much less common among Jews than among Christians, probably on 
account of the practice of circumcision among the former. At the 
Metropolitan Free Hospital, situated in the Jews' quarter, London, 
in 1854, the proportion of Jews to Christians among the out-patients 
was nearly one to three ; yet the ratio of cases of syphilis in the 
former to those in the latter was only one to fifteen ; and that this 
difference was not due to their superior chastity was evident from 
the fact that the Jews furnished nearly half the cases of gonorrhoea 
that were treated during the same period. Mr. Hutchinson's obser- 
vations also lead him to believe that hereditary syphilis is much 
rarer among the children of Jews than Christians ; and the experi- 
ence of most surgeons will confirm the fact that persons with a long 
prepuce, and especially those affected with congenital phymosis, are 
peculiarly subject to venereal diseases. 

1 Medical Times and Gazette, Dec. 1, 1855. 



PHYMOSIS. 121 

The size of the preputial orifice in congenital phymosis varies in 
different cases. In some, it is large enough to permit of the partial 
exposure of the glans and the removal of the natural secretion of 
the part, at least with the assistance of a syringe and injections of 
warm water ; while in others, it is so contracted that it is difficult 
or even impossible to uncover the meatus ; whence it happens that 
the entrance of the urine at each act of micturition beneath the 
prepuce, and the collection of sebaceous matter, maintain a constant 
state of irritation and even chronic inflammation, to which most of 
the adhesions met with between the opposed surfaces are undoubt- 
edly attributable. 

Daily observation proves that congenital phymosis is not incon- 
sistent with a state of perfect health ; and yet when we reflect upon 
the sympathy existing between different portions of the genito- 
urinary apparatus, and between the latter and other organs, we 
might reasonably expect- to meet with at least occasional instances 
in which irritation of the head o£ the penis due to this cause gives 
rise to disturbance in other parts of the body. These anticipations 
are realized in practice ; but, according to Fleury, 1 who has ably 
investigated this subject, such disturbance is to be attributed more 
to the extreme sensitiveness of the balano-preputial membrane con- 
stantly protected from friction and exposure to the air, than to the 
irritation of collections of sebaceous matter ; since it is often present 
even when the condition of the parts admits of the most perfect 
cleanliness. 

Among the symptoms which have been ascribed to congenital 
phymosis are : balanitis, constant itching and even pain at the head 
of the penis, inordinate excitability of the genital organs, frequent 
erections, erotic dreams, seminal emissions, imperfect development 
of the penis and testicles, incomplete and painful ejaculation of the 
sperm, vesical tenesmus, incontinence of urine, gastralgia, neural- 
gia, and general lassitude and prostration. Probably no one will 
be disposed to call in question the occasional connection between 
the milder of the above affections and phymosis. With regard to 
the others, some doubts might be legitimately entertained, were it 
not for the circumstantial report of the symptoms, and the fact that 
simple excision of the elongated prepuce has in most cases brought 
complete and permanent relief. 2 

i Gaz. des Hop., Oct. 30, 1851. 

2 Fleury's observations have been fully confirmed by Borelli (3faladies genito- 
vesicates, Gaz. des Hdp., Dec. 1851); Anagnostaxis relates a cure of amblyopia by 
the excision of the prepuce (Rev de. Thir. Med.-Chir., No. 4, 1850); and Trousseao 
one of incontinence of urine by the same operation (Gaz. des Hop., No. 9, 1860). 



122 PHYMOSIS. 

Verneuil reports a very interesting case in which careful micro- 
scopical examination of the excised prepuce showed that the termi- 
nal plexus of nerves had become hypertrophied, and in which the 
nervous symptoms were thus fully accounted for. 1 

Accidental phymosis may depend upon any cause enlarging the 
glans penis to such an extent that it will not pass through the pre- 
putial orifice, or occasioning such an amount of thickening or con- 
traction of the prepuce that it cannot be retracted ; in other words, 
the seat of the difficulty may be either in the glans or its covering. 

In some cases the obstruction is simply mechanical, as from vege- 
tations within the balano-preputial fold, the induration surrounding 
a chancre, or the cicatrization of any ulcer situated upon the margin 
of the prepuce. 

More frequently it originates in inflammatory action, as idiopathic 
balanitis or posthitis, or the same affections excited by the presence 
of ulcers, secondary eruptions, vegetations, etc., either of which 
may occasion swelling of the glans or infiltration in the lax cellular 
tissue of the prepuce. 

There is still another cause of phymosis which, strictly speaking, 
cannot be included among those just mentioned; I refer to a peculiar 
thickening of the mucous membrane and submucous tissue, ob- 
served both in men and women after the cicatrization of a chancroid 
or chancre, and which consists neither in specific induration nor 
oedema, but in hypertrophy of the normal tissues of the organ. 
Grosselin believes that this effect is peculiar to venereal ulcers. It 
is most frequently found in the labia minora in women, and in the 
prepuce in men. ' In the latter the envelope of the glans may 
become so thickened that its retraction may be very difficult and 
give rise to fissures of the preputial orifice, or may be quite im- 
possible. 

Treatment. — In congenital phymosis attended by any of the 
unpleasant effects alluded to at the commencement of .this chapter, 
circumcision is the only sure means of relief; but if, from any 
cause, an operation be impracticable, the patient should be directed 
at each act of micturition to expose the meatus as perfectly as 
possible in order to prevent the retention of the urine beneath the 
prepuce. 

In accidental phymosis, the rule is to avoid an operation if possi- 
ble, unless congenital phymosis has previously existed ; but when 

1 Archives Ge'ne'rales de Me"d., Nov., 1861. 



TREATMENT. 123 

due to vegetations beneath the prepuce, or to contraction of the pre- 
putial orifice from the cicatrix of a chancroid which has entirely 
healed, an operation may be necessary to gain access to the abnormal 
growths or to restore the opening of the prepuce to its original size. 

Phymosis dependent upon a large mass of specific induration, of 
which I have met with several instances, disappears under the inter- 
nal administration of mercurials. 

An operation should, if possible, be avoided or deferred when the 
phymosis is due to acute inflammation, which may in most cases be 
subdued by rest in the horizontal posture, low diet, cathartics, 
leeches to the groin or perineum (not upon the prepuce), a lead and 
opium wash, and, if it be certain that no chancroid is present, by 
scarifications j but if gangrene threaten, delay is no longer justifi- 
able. 1 

In some instances, we are certain that an ulcer is concealed be- 
tween the prepuce and glans, where it may have been seen either by 
the patient or surgeon before the phymosis supervened ; in others, 
its existence is highly probable, from the fact that the patient has 
been exposed in promiscuous intercourse. Now the mere suspicion 
of an ulcer within the hidden folds of mucous membrane is suffi- 
cient to induce great caution in resorting to an operation which may 
be followed by inoculation of the edges of the wound. It is indeed 
true that if the sore be a chancre, auto-inoculation will not be likely 
to take place ; but it may be of the mixed variety, or there may be 
both a true chancre and a chancroid ; hence the fact that a mass of 
induration can be felt beneath the prepuce is not sufficient of itself 
to justify an operation. A case in point has fallen under my own 
observation : A medical friend was called to treat a case of phymosis 
dependent upon an ulcer, surrounded by a cartilaginous mass of 
induration which could be felt beneath the prepuce. Eelying upon 
the fact that a chancre cannot be inoculated upon the person bearing- 
it, he resorted to an operation ; in a few days the edges of the wound 
assumed the appearance of a chancroid. The original ulcer was 
undoubtedly of the mixed variety. 

Under some circumstances, however, and especially with gangrene 
threatening, an operation cannot be avoided, and the prepuce should 
be slit up by means of a curved bistoury carried along a director, 
which has been introduced from the orifice to the angle of reflection ; 
but the incisions should be carefully protected from contact with 
the virus, and, if inoculated, should be cauterized with nitric acid. 

1 This point will be farther discussed in the chapter on the chancroid. 



124 PHYMOSIS. 

The thickening of the substance of the prepuce, already described 
as a sequela of venereal ulcers, is rarely so great as to produce com- 
plete phymosis ; but the difficulty attending the exposure of the 
glans and the frequent rents which the act occasions, often justify 
the removal of the hypertrophied tissues. 

Circumcision. — Partial operations for phymosis,' as, for instance, 
slitting up the prepuce along the dorsum, or excision of a triangular 
portion, often fail to afford permanent relief and leave the organ in 
a misshapen condition. The purposes of elegance and utility can 
best be subserved by circumcision. 

Before describing this operation, let me remind the student that 
the prepuce is composed of two layers, separated by cellular tissue 
of such lax texture as to admit of an almost indefinite amount of 
motion between them. The internal or mucous layer is firmly 
attached to the penis posterior to the corona glandis, and hence is 
incapable of being drawn forwards to any great extent in front of 
the glans. The external or integumental layer, on the contrary, is 
continuous with the flaccid skin of the body of the penis, and may 
be elongated almost indefinitely ; its anterior portion doubling in 
upon itself as the posterior is drawn forwards. It follows from this 
anatomical arrangement, that a section of the prepuce in front of the 
glans can only include the integumental together with an insignifi- 
cant portion of the mucous layer. 

Of the various methods of performing circumcision recommended 
by different authors, I prefer the following : — 

The patient should be upon the bed where he is to lie until cica- 
trization is accomplished, in order after the operation to avoid 
unnecessary motion and hemorrhage, which would interfere with 
speedy union ; and if he is incapable of self control, he should be 
etherized. The requisite instruments are a pair of long-bladed 
forceps, a sharp-pointed bistoury, blunt-pointed scissors, and sutures 
of iron or silver wire, or serres-fines. 

Allow the penis to hang without traction in its natural condition, 
and with a pen and ink trace a line upon the skin corresponding to 
the corona glandis, to serve as a guide for the incision. Next draw 
the prepuce forwards, until this line is in front of the glans, and 
grasp it between the long blades of the forceps (somewhat more 
obliquely than is represented in the adjoining cut, so as to include 
a larger portion of the prepuce above than below), which should be 
intrusted to an assistant ; the external part is now to be excised in 
front of, and close to the blades of the forceps, having first been put 
upon the stretch by the left hand of the operator. Any attempt to 



CIRCUMCISION. 



125 



Fiff. 2. 




(After Phillips.) 



cut from either margin of the fold will be attended with' some diffi- 
culty, since the several layers of the skin and mucous membrane 
oppose an amount of resistance to the knife that is not readily 
overcome ; hence, it is better to transfix the centre of the flap (the 
blade of the knife parallel to, in front of, and in contact with the 
forceps), cut downwards, and complete the section by turning the 
knife, and cutting upwards. 

The assistant should now remove the forceps, when the integu- 
ment will retract, carrying its cut edge back to the base of the glans, 
and exposing the raw external surface of the mucous membrane 
which still covers the glans. If the mucous membrane be in a 
healthy condition, it may be divided with scissors along the dorsum, 
and turned back to be united to the integument ; but if thickened 
by chronic inflammation, vegetations, or the cicatrix of an ulcer, 
more or less of it should be excised. The parts should not be 
brought into coaptation until the bleeding has been arrested by 
exposure to the air, and torsion of the small vessels. Union may be 
effected by means of sutures of iron wire, or serres-fines, which 
should be removed as soon as the edges of the wound are securely 
glued together with lymph, or within twenty-four or forty-eight 



126 PH-YMOSIS. ( 

hours. . I prefer simple exposure to the air, and protection by means 
of a cradle from contact with the bedclothes, to the water-dressing 
commonly employed, unless union by first intention fails to take 
place, and suppuration ensues. The patient should remain in bed 
until the parts have entirely healed, and, if the contact of the urine 
with the wound cannot be otherwise prevented, "should micturate 
with his penis immersed in a basin of tepid water. In favorable 
cases, confinement to the house for two or three days is sufficient. 

It would hardly seem necessary to caution the surgeon not .to 
excise too large a portion of the integument, were it not for the fol- 
lowing case reported by ISTelaton : * A patient appeared at the cli- 
nique who had been operated upon for phymosis eleven days before 
by the usual method. The physician, forgetting that the integument 
of the penis is very lax and extensible, had, before making the inci- 
sion, drawn it forwards to its utmost limits ; the consequence was 
that, after the operation, the penis was denuded nearly to the abdom- 
inal wall. An extensive suppurating surface had remained, which 
was torn and made to bleed by frequent erections. The case does 
not appear to have been followed to its termination, but Kelaton 
remarks upon the rigidity and malformation of the organ, pro- 
vided cicatrization should take place, and adds that "this case 
shows the importance of marking the limits of the incision before 
the operation." 

The American editor of Erichsen's Surgery states that the favorite 
operation for phymosis at the Pennsylvania Hospital, Philadelphia, 
consists in simple division of the mucous layer of the prepuce, by 
means of fine scissors, one blade of which is sharp, and the other 
probe-pointed. The former is made to penetrate between the two 
layers of the prepuce along the dorsum of the organ, while the latter 
passes between the glans and its envelope, and thus the internal 
layer may be divided as far as the corona glandis. The prepuce 
should be retracted several times each day, especially during mic- 
turition, both in order to prevent contact of the urine with the wound, 
and also immediate union, which would thwart the purpose of the 
operation. 

Faure accomplishes the division of the mucous layer in a simpler 
mariner, as follows : The skin of the penis is forcibly drawn towards 
the abdomen, when an incision is to be made with blunt-pointed 
scissors upon the dorsum of the retracted preputial orifice, impli- 
cating the mucous membrane, but sparing the integument. This 
allows of a still farther retraction of the prepuce, bringing into 

1 Pathologie Cbirurgicale, t. v., p. 6G3. 



I circumcision. 127 

view an additional portion of mucous membrane, which, by a suc- 
cession of the above procedures, may be divided to the base of 
the glans. 

Jobert (de Lamballe) makes an incision from the preputial orifice 
on each side of the frsenum as far as the corona glandis ; then cuts 
off the fraenum, which is now included in a small triangular flap ; 
and finally unites the skin and mucous membrane by the inter- 
rupted suture, thus leaving the greater portion of the prepuce intact 
and merely enlarging its orifice beneath. 1 

These methods, unattended by any loss of substance, may suffice 
when it is desired simply to relieve uncomplicated phymosis ; but 
when the mucous membrane is in a diseased condition, as is gener- 
ally the case when an operation is required, circumcision should be 
preferred. 

4 Gaz. des Hop., Aug. 27, 1861. 



128 PARAPHYMOSIS. 



CHAPTER V. 

PARAPHYMOSIS. 

In paraphymosis the extremity of the penis is strangulated by a 
narrow preputial orifice retracted behind the prominent corona 
glandis, which forms the chief obstacle to reduction. After the 
lapse of a few hours or days, the parts behind and especially in 
front of the stricture become swollen from infiltration of serum and 
fibrine ; the constricting ring is concealed in a deep furrow between 
them, and is still farther retained in its abnormal position by adhe- 
sion to the deeper textures — the result of inflammatory action. 
Ulceration or gangrene may finally supervene, and perhaps relieve 
the stricture, but with an unnecessary loss of tissue. 

Paraphymosis is frequently met with in boys, as the result of their 
first attempt to expose the glans. It may also follow the injudicious 
retraction of the prepuce when previously affected with phymosis, 
and while the parts are still in an inflamed condition. 

Treatment. — When called to a case of paraphymosis, it may 
not be advisable to attempt reduction until the oedema has first been 
diminished by rest in the horizontal posture, elevation of the penis, 
and a saline cathartic, assisted in some cases by scarification of the 
swollen tissues in front of the stricture, the application of ice or a 
stream of cold water directed upon the part. 

Eeduction may often be facilitated by placing the patient under 
the influence of an anaesthetic. The difficulty is frequently increased 
by the vicious manner in which the attempt is made. The swollen 
glans and mucous layer of the prepuce are to be passed through a 
narrow preputial orifice. Mere pressure from before backwards 
will increase their transverse diameter and augment the difficulty 
of reduction ; this can be best accomplished by compressing, and, 
if necessary, elongating them, and drawing the constricting ring 
and integumental layer over them. 

To effect this purpose, let the parts in front of the stricture be 
well-oiled, and the glans enveloped in a thin rag, that it may afford 



TREATMENT. 



129 



Fie. 3. 




(After Phillips. 



a firmer hold to the fingers. The surgeon steadily compresses the 
glans for ten or fifteen minutes in its transverse diameter, with the 
thumb and fingers of his right hand, and endeavors to relieve its 
distended vessels of a portion of their contents. He then encircles 
the body of the penis with the thumb and fingers of his left hand, 
and draws the integument forwards, 
attempting at the same time to insert 
the right thumb nail beneath the stric- 
ture, and elevate it above the corona 
glandis, which is most prominent upon 
its superior aspect. 

Steady perseverance in , the above 
method will rarely fail of success, 
when reduction is possible ; but the 
following modes, recommended by dif- 
ferent authors, are perhaps worthy of 
description. 

In an ingenious method proposed 
by M. Garcia Teresa, the centre of a 
piece of tape is placed upon the dor- 
sum of the corona glandis, the oppo- 
site ends passed round the sides of the 

glans, crossed beneath the frsenum, and wound around the little finger 
of each hand ; the glans is then compressed by flexing the middle 
and ring fingers, and exercising traction in opposite directions, while 
the other fingers remain free to draw the prepuce forwards, and 
accomplish its reduction. 1 

Dr. Yan Dommelen effects compression of the glans by winding 
around it a strip of adhesive plaster half a yard long, and about a 
quarter of an inch wide, commencing at its base, and terminating 
near the orifice of the urethra. 2 

M. Seutin, of Brussels, has invented a pair of forceps with spoon- 
shaped extremities, to maintain compression of the glans until the 
constricting ring can be drawn over them. 

The three preceding methods are designed for the purpose of com- 
pressing the glans during reduction ; in the following, which is said 
to be employed with great success at the Children's Hospital, in 
Pesth, compression of nearly the whole organ precedes the attempt 
to restore the preputial orifice to its normal position : — 

The penis is first well cleansed and dried, when a strip of adhesive 

1 Rev. de Ther. MeU-Chir., Feb. 15, 1860. 

2 Med. Times and Gaz., June 4, 1859. 

9 



ISO PAKAPHYMOSIS. 

plaster, about three lines broad, is applied longitudinally from the 
middle of its under surface, over the swollen prepuce and glans, 
avoiding the meatus, to the middle of the upper surface. Another 
strip is carried in a similar manner from side to side over the glans, 
and in large boys a third, and even a fourth strip, may be required 
to cover the whole organ. Finally, still another strip is firmly ap- 
plied transversely over the preceding, commencing just behind the 
meatus, and continued by successive turns to the middle of the body 
of the penis. The application is said to be weli borne, and the swell- 
ing so diminished within twenty-four hours, tha.t the plaster must be 
renewed ; reduction can usually be effected within forty-eight hours. 

The late Abraham Colles, Prof, of Surgery at the Eoyal College 
of Surgeons in Ireland, succeeded, after other means had failed, in 
relieving two severe cases of paraphymosis, by passing a director 
beneath the stricture from before backwards, and elevating it upon 
the point of the instrument, while the stem was made to compress 
the swelling in front, and gradually force it back beneath the stric- 
ture. This process was repeated on each side of the penis, after 
which reduction was quite easy. 2 

When reduction is impossible, and ulceration or gangrene threat 
ens, it becomes necessary to relieve the stricture, by dividing the 
preputial ring, which — as should not be forgotten — is situated at the 
base of the furrow between the swollen folds of mucous membrane 
and integument. This may be done by entering a narrow, sharp- 
pointed bistoury flatwise, and from before backwards, upon the dor- 
sum of the penis, turning its edge upwards, and dividing the stric- 
ture. In some cases, this procedure must be repeated in several 
peaces, and the swollen prepuce freely scarified, before reduction can 
be effected. 

1 Schmidt's Jahrbucher. 

2 Dublin Quart. Journ. of Med. Sci., May, 1857. 



SWELLED TESTICLE. 131 



CHAPTER VI. 

SWELLED TESTICLE. 

The most frequent complication of gonorrhoea is an affection of 
the scrotal organs, variously known by the names of swelled testicle, 
hernia humoralis, orchitis, and by the more correct term, gonorrhoeal 
epididymitis. In order to understand the mode in which this com- 
plication supervenes upon gonorrhoea, it is desirable to recall to 
mind the canal which connects the testicle and the urethra, and 
which is designed for the passage of the seminal fluid. Tracing 
this canal from before backwards, we have first the aperture of the 
ejaculatory duct, near the anterior extremity of the veru montanum 
in the prostatic portion of the urethra ; following this duct, we find 
that it merges into the vas deferens, which passes round the bladder, 
through the spermatic canal «in the abdominal muscles, and finally 
descends within the scrotum, where it terminates in the numerous 
and intricate convolutions of the epididymis. We thus have a pas- 
sage, lined with mucous membrane, which is continuous with the 
mucous membrane of the urethra, and connects the deepest portion 
of this canal with the epididymis. 

In the early stages of urethral gonorrhoea, the inflammation is 
generally confined to the neighborhood of the fossa navicularis. 
At a later period, however, the deeper portions of the canal are 
involved, and the disease thus gains access to the ejaculatory duct, 
and, under the influence of any exciting cause, may extend along 
the spermatic canal to the epididymis, or even beyond this, to the 
testicle and the tissues which envelope it. The patient's own sensa 
tions will sometimes indicate that in this mode has originated the 
affection of the testicle. He has felt a dull pain in the perineum 
and in the groin, along the course of the spermatic vessels, for a 
day or two before he observed the tenderness and swelling of the 
testis. Again, we may find additional evidence in the fact that the 
cord corresponding to the inflamed testicle can be felt externally to 
be swollen and hard, and can be traced from the testicle through 
the inguinal canal, even into the iliac fossa. Post-mortem exanp • 



132 



SWELLED TESTICLE. 



nations, also, have exhibited the ordinary appearances of inflamma- 
tory action throughout the whole of the canal connecting the 
testicle and urethra. There can be but little doubt, therefore, that 
in many, and probably in most cases, swelled testicle owes its origin 
to the extension of the inflammation along a continuous mucous 
surface. 

In some cases, however, no evidence of such extension can be 
found either in the sensations of the patient, or in any abnormal 
condition of the cord, which appears to be entirely unaffected. 
These cases are analogous to the inflammation of a lymphatic 
ganglion in the groin or axilla, in consequence of a wound of the 
foot or hand ; the lymphatic vessel connecting the two exhibiting 
no symptoms of inflammation. It may be that the inflammation 
has traversed this vessel, but that its passage has been so rapid as 
not to excite notice, and to leave no traces behind it ; or it may be 
that particles of irritant matter have been conveyed along the duct, 
and lodged in the ganglion. A similar explanation is given in 
cases of swelled testicle without appreciable lesion of the cord, by 
those who refuse to admit any other origin for this disease than the 
direct extension of the inflammatory process. Most authorities, 
however, admit that swelled testicle may be excited through sym- 
pathy alone, without any inflammation, however slight, of the 
spermatic tract, or any passage of irritant matter; and the sub- 
sidence of the swelling in one testicle, and its subsequent appear- 
ance in the other, as is observed in some cases, renders this view 
probable. 

Causes. — Gonorrhoea of the urethra is the only form of gonor- 
rhoea which gives rise to swelled testicle, which is never met with 
as a complication of balanitis. 

The following table, drawn up by M. de Castelnau, 1 exhibits the 
times of its appearance in the course of the gonorrhoea, in 239 
cases, collected from different sources : — 





Gauss ail. 


Despine. 


Aubrey. 


De Castelnau. 


Total. 


1st week . . . 


3 


2 


8 


3 


16 


2d " . 


4 


6 


17 


7 


34 


3d " . . 


5 


2 


9 


8 


24 


4th " 


16 


2 


15 


6 


39 


5th " 


39 


2 


8 


5 


54 


6th " and later 


6 


15 


43 


8 


72 




— 


— 





— 





Total, 


73 


29 


100 


37 


239 



i Annales des Maladies de la Peau et de la Syphilis, May, 1844. 



CAUSES. 133 

In the experience of most surgeons, swelled testicle is even rarer 
during the first fortnight of a gonorrhoea, than would appear from 
the above statistics. As a general rule, it may be said to supervene 
after the third week, and most frequently after the sixth week. 

Cases are reported in which it has occurred after the discharge 
had entirely disappeared, and in one as late as three months. A 
patient once came to me with swelled testicle, five weeks after I had 
treated him for a clap, and had dismissed him as cured, and he 
assured me that he had not perceived any discharge in the mean- 
while, nor could I discover any upon examining the penis. It is 
probable, as stated by Yelpeau, that in these cases there still remains, 
in the prostatic portion of the urethra or at the neck of the bladder, 
a small amount of inflammation, but not sufficient to manifest itself 
externally. 

Instances are recorded in which the swelling of the testicle is said 
to have appeared before the discharge from the urethra. In one 
case reported by M. Castelnau, the epididymitis was developed a 
week after coitus, and the urethral running was first seen five days 
afterwards. M. Yidal (Ann. de Ohir., 1844) gives a similar case, and 
Yelpeau {Diet, de Med., art. Testicule) admits such an occurrence. It 
is not improbable that a gonorrhoea really existed, but was over- 
looked, in these cases ; still it is possible that the prostatic portion 
of the urethra alone received the irritation from coitus, and that the 
effect produced was insufficient to manifest itself by a discharge until 
after the swelling of the testicle had taken place. 

In some instances we are able to trace an attack of swelled testicle 
directly to some exciting cause, which has aggravated the urethral 
disease. Thus the patient may have been imprudent in exercising 
or in exposing himself to cold, or he may have indulged in a 
debauch or in sexual intercourse. Strongly irritant injections, or 
any violence done to the canal by a large bougie, or by forcible 
distention when using a syringe, may also occasion it. One of the 
most severe cases of this disease that I ever met with had been 
induced by the forcible introduction of a large bougie in the treat- 
ment of a gleet of several years' duration. In other instances, 
however, the exciting cause of epididymitis is not apparent, inde- 
pendently of the fact that the inflammatory action has had time to 
involve the prostatic portion of the urethra and gain access to the 
spermatic ducts. It has been supposed by some surgeons, that the 
use of copaiba and cubebs is occasionally the cause of epididymitis ; 
while others have not only denied this, but have even recommended 
these drugs in the treatment of this affection. I have already 



134: SWELLED TESTICLE. 

referred to this subject in speaking of the anti-blennorrhagics, and 
will only say at present that evidence is wanting in favor of both 
these assertions. We have no reason to believe that copaiba and 
cubebs ever occasion this disease, and still less reason to believe that 
they can be used with benefit in its treatment. 

It should not be forgotten that wearing a well-fitting suspeosory 
bandage during an attack of gonorrhoea is the best protection 
against swelled testicle. The patient is thus relieved of the weight 
of the scrotal organs, the flow of blood from the part is facilitated, 
and the liability to inflammatory action is consequently much 
diminished. 

Seat. — Gonorrhceal epididymitis more frequently attacks the left 
testicle than the right. Of 1342 cases observed by Prof. Sigmund, 
of Vienna, the left testicle was affected in two-thirds. 1 The greater 
frequency of this disease on the left side has been attributed by 
some authors to the fact that men usually " dress " on this side, and 
that the left testicle consequently receives less support than the 
right. This explanation, however, is very questionable. The differ- 
ence is doubtless to be found in that cause, as yet not explained in 
a perfectly satisfactory manner, which renders the left testicle more 
prone than the right to take on various .forms of morbid action. 
Both testicles rarely become inflamed simultaneously, but not unfre- 
quently one is attacked after the other. This usually occurs only 
after the lapse of several weeks, though I have seen the two attacks 
separated by only a few days' interval. Sigmund states that both 
testicles were affected in seven per cent, of his hospital patients, and 
in five per cent, of his private cases. Occasionally, the inflammation, 
after leaving one testicle and attacking the other, will return to the 
first ; to this form of the disease Eicord has given the expressive 
name of see-saw epididymitis. 

The best authorities, with but few exceptions, agree in the state- 
ment that it is the epididymis, of all the scrotal organs, which is 
first and chiefly involved in most cases of this disease. It is here 
that the vas deferens terminates, and we may suppose that the inflam- 
matory action is retarded in its progress by the innumerable and 
intricate convolutions which compose this appendage to the testicle. 
A.t an early stage of the inflammation, and also after the swelling 

1 British and Foreign Medico-Chirurgical Review, Oct. 1856. 

Mr. Curling denies that the left testicle is most frequently affected (Diseases of the 
Testis, p. 226), but his statement is founded on 138 cases only, which are far inferior 
»n number to the above statistics of Prof. Sigmund. 



SEAT. , 135 

has somewhat subsided, the epididymis can be felt enlarged to 
several times its natural size. The normal position of the epididy- 
mis is posterior and external to the body of the testicle, and pressure 
upon this part excites more pain than elsewhere. The epididymis. 
not being enveloped, like the testicle, in a fibrous capsule, is suscep- 
tible of an indefinite amount of tumefaction, and frequently enlarges 
to such an extent as to partially surround and encase the body of 
the testis. 

It should be recollected, however, that the position of the epi- 
didymis, relative to the testicle, may be abnormal ; in which case 
the seat of the greatest tenderness and swelling will differ from the 
description just now given. Such malpositions are called by the 
French inversions du testicule. They have recently been thoroughly 
investigated for the first time by M. Eugene Royet, 1 who admits the 
five following varieties : — 

1. The epididymis may be anterior to the body of the testicle. 

2. It may be on one side, either the external or internal. 

3. It may be superior ; the long axis of the testis being antero- 
posterior, and the epididymis resting upon its upper surface. 

4. In the fourth variety, the epididymis and vas deferens form a 
loop or sling, which surrounds the testis from before backwards. 

5. In the fifth variety, the relative position of the epididymis and 
testis varies from day to day, without appreciable cause. 

All these varieties are rare, with the exception of the first, which, 
according to Royet's researches, is met with in one out of every 
fifteen or twenty persons. The abnormal position of the epididymis 
in front of the testicle is, therefore, the only one possessing much 
practical importance. The possibility of this malposition should be 
borne in mind both in operating for hydrocele and when forming a 
diagnosis of scrotal tumors. In cases of epididymitis, when the in- 
flammation is not general, the epididymis may be recognized by its 
hardness to the touch and its sensibility to pressure. "When all the 
scrotal organs are involved in the inflammatory process, Royet 
states that, the chief means of recognizing an anterior position of 
the epididymis, are a want of mobility in the skin anteriorly, owing 
to its adhesion at this point to the epididymis and the fact that the 
vas deferens can be felt in front, instead of behind the other vessels 
of the cord. 

Next to the epididymis, the tunica vaginalis is most frequently 
involved in gonorrhoeal epididymitis. M. Rochoux has advanced 
the idea that inflammation of this membrane is the chief and con- 

1 De l'lnversion du Testicule ; Paris, 1859, p. 55. 



136 SWELLED TESTICLE. 

stant lesion in swelled testicle; 1 but this is a mistake. Yaginali- 
tis, although a very frequent, is not a constant symptom, and is 
always consecutive to the inflammation of the epididymis. There 
is commonly an effusion varying in quantity and character, within 
the tunica vaginalis. This may consist only of serum and be ap- 
parently due to simple obstruction of the circulation; or it may 
contain fibrin and other products of inflammation. Sometimes bands 
of lymph bind the two opposed surfaces together, as in pleurisy. 
The sub-scrotal cellular tissue also participates in the inflammatory 
action, and is thickened by oedema or fibrinous deposit. The fre- 
quency with which the tunica vaginalis is involved in swelled tes 
tide, while the body of the testicle is unaffected, has been explained 
by Gendrin, 2 who states that when the cellular tissue of an organ is 
continuous with that underlying a neighboring serous membrane, it 
becomes a ready means of communicating inflammatory action ; but 
when a contiguous organ is not thus connected with the original 
seat of the disease, the passage of the inflammation is less easy. The 
connecting link between the epididymis and tunica vaginalis is 
found in the areolar tissue which penetrates the former and underlies 
the latter, while the testicle is surrounded by the fibrous tunica 
albuginea, and, being thus isolated, generally escapes. 

Following the tunica vaginalis in the order of frequency, the 
spermatic cord is next found to be the seat of inflammatory action in 
gonorrhoeal epididymitis. The body of the testicle is rarely affected ; 
and even when involved, the fibrous tunic which invests it limits 
the amount of swelling of which it is capable, although it greatly 
increases the suffering of the patient by constricting the inflamed 
tissues. 

Some idea of the comparative frequency with which the different 
tissues' now mentioned are attacked in this disease may be formed 
from the statistics of Prof. Sigmund, already referred to. In 1342 
cases, the epididymis was alone affected in 61 ; the epididymis and 
tunica vaginalis in 856 ; the epididymis and cord in 108, and these 
three parts together in 317. 

The propriety of the name, gonorrhoeal epididymitis, will now 
be evident. It is no objection to this term that the epididymis, in 
many cases, is not the only part involved. As in diseases of the 
eye, we call a certain inflammation iritis, though other parts besides 
the iris are involved, so in swelled testicle, the principal seat of the 

i Du Siege et de la Nature de la Maladie improprement appellee Orchite Blennor- 
rhagique, Arch. Gen. de M6d., 2e s6rie, 1833, t. ii., p. 51. 
2 Histoire Anatomique des Inflammations, t. i. p. 143. 



SYMPTOMS. 137 

disease should determine its scientific name. The term orchitis,. 
which is adopted by Yidal, Velpeau, and most English authors, is 
less correct, and is moreover objectionable, because it is calculated 
to confound this disease wi-th that affection of the testicle which is 
produced by syphilis, and which is totally distinct in its character 
and symptoms. 

Symptoms. — There are generally no marked premonitory symp- 
toms preceding an attack of swelled testicle. Sometimes, however, 
we find that the patient has suffered from malaise for several days ; 
that he has had slight fever, perhaps a chill, and a dull pain or 
heavy sensation in the perineum, cord, and scrotal organs, attended 
with a frequent desire to pass water. His attention is soon attracted 
to the testicle by pain, felt especially £>n motion, and on examination 
he finds this organ swollen, and tender on pressure. The swelling 
and tenderness rapidly increase, and the pain extends to the corre- 
sponding thigh, to the groin, and to the lumbar region. In the 
course of twenty -four or forty-eight hours, the affected side of the 
scrotum may have attained the size of the fist ; the skin is tense 
and in some cases of a dark red or almost purplish hue ; the pain is 
very severe, especially at night, preventing sleep ; the least pressure 
upon the part, even from the bedclothes, is almost unendurable; 
partial ease only can be attained by keeping perfectly quiet in the 
horizontal posture with the addition of some support to the genital 
organs. If the cord be involved, the pain, swelling, and tenderness 
are found to extend upwards to the inguinal canal. There is gen- 
erally more or less febrile disturbance of the system at large. The 
skin is hot, the tongue coated, the pulse increased in force and 
frequency, and the patient extremely nervous and agitated. Cases 
are reported in which the swelling of the cord was so excessive as 
to produce strangulation at the abdominal ring, attended by symp- 
toms resembling those of strangulated hernia, such as abdominal 
tenderness and vomiting. It must not be supposed, however, that 
the symptoms are always so severe as those now described. Such 
severity is more apt to be met with in persons of a nervous temper- 
ament, in whom this disease is one of the most distressing that can 
occur. In other cases, however, the suffering is comparatively 
slight, and I have known patients to attend to their daily occupa- 
tion during its whole course. Between these two extremes we may 
have every shade of variation. 

While the inflammation is at its height it is impossible to distin- 
guish the different portions of the scrotal organs. Judging from 



188 SWELLED TESTICLE. 

mere inspection of the swelling, we might be led to suppose that it 
was chiefly made up of the body of the testicle. This, however, is 
not so. It is composed, for the most part, of the swollen epididy- 
mis, of an effusion into the tunica vaginalis, and of oedema of the 
subscrotal cellular tissue. The hydrocele is often, but not always, 
sufficient to enable us to detect distinct fluctuation, and rarely, if 
ever, is the tumor transparent ; but on gently touching it, the sur- 
face is found to yield for a short distance before the fingers come in 
contact with the firmer body of the testicle beneath. This yielding is 
due to the displacement of the oedema of the scrotum and of the fluid 
in the sac. If the tumor be punctured with a lancet, bloody serum, 
varying in amount from a few drops to several drachms, will escape. 

Eesolution begins to take place in a few days, commencing in the 
anterior portion of the tumor. The oedema of the scrotum and the 
hydrocele disappear, and the different portions of the testis can now 
be distinguished from each other — the epididymis, still swollen and 
hard, behind ; and the body of the testicle, preserving, in most 
cases, its normal elasticity, in front. The whole duration of the 
attack varies from one to three weeks. In a discussion on the treat- 
ment of this disease before the Academy of Medicine in Paris, in 
1854, Yelpeau stated that its duration under ordinary methods of 
treatment averaged 16 to 18 days. 

In some cases of swelled testicle, after the more acute symptoms 
have subsided, the parts still remain engorged and the disease shows 
a tendency to become chronic. This is most likely to occur in 
patients of weak habit, and while this condition lasts the least ex- 
citing cause may induce a return of the acute inflammation. 

Most cases of swelled testicle terminate favorably. In some rare 
instances, however, abscesses form in the cellular tissue underlying 
the scrotum, or in the epididymis or body of the testicle. Mr. 
Edwards 1 has recently reported a case in which the whole testicle 
protruded through an opening formed by an abscess in the scrotum, 
the skin being drawn in around the orifice. Mr. Edwards " pared 
the edges, drew them asunder, making with the handle of the 
scalpel a sufficient separation of the deeper tissues, and the testicle 
was at once drawn, as it were, back into the scrotum, the wound 
closing over it. Three hare-lip pins were inserted ; the wound 
closed by first intention, and the patient was walking about per- 
fectly well on the seventh day." If an abscess form and be not 
early evacuated, the pus generally burrows in various directions, 

i Edinb. Med. Journal, Nov., 18C0, p. 455. 



SYMPTOMS. 139 

# 

forming sinuses, and destroying a portion of the parenchyma, "but 
the loss of a portion of the organ does not appear to be followed by 
any disturbance of its function ; sometimes a circumscribed abscess 
is formed, which may become encysted, and, the more fluid portion 
being absorbed, the solid portion may remain in a concrete state for 
an indefinite length of time, and closely resemble a tubercular 
deposit. The presence of the cyst will clear up the diagnosis, since 
true tubercular matter is always found in direct contact with the 
parenchyma of the testis, and is never encysted. 

The swelling of the testicle attendant upon gonorrhoea may, how- 
ever, be the exciting cause of true tubercular deposit, in persons of 
a strumous diathesis. 1 

As the epididymis was the first part attacked, so it is the last to 
recover its normal condition, and in some cases it retains, for months 
or years, an irregular and knotty mass of induration, which may 
obstruct the passage of the semen and render the affected testis use- 
less. If this induration exist on both sides, or if the opposite testicle 
be undeveloped, as is often the case with an undescended testis, 
the patient will probably be impotent. In a few rare cases gonor- 
rhoeal epididymitis has been known to terminate in atrophy of the 
testicle. Hypertrophy is extremely rare, but is sometimes seen in 
persons who have had frequent attacks of swelled testicle. 

The condition of the urethral discharge preceding and during an 
attack of swelled testicle has been the subject of considerable dis- 
cussion. It was at one time supposed that this complication of 
gonorrhoea was usually preceded by a diminution of the running, 
and hence that it might be attributed to the use of active measures 
which were supposed to drive the disease from the urethra to the 
testicle. On this supposition has been founded the theory that 
swelled testicle may be caused by metastasis. A proper appreciation 
of the facts in the case, however, does not warrant this conclusion. 
It is, indeed, true as a general rule, that the urethritis has passed 
the acute stage, and that the discharge has consequently diminished 
before the epididymis becomes inflamed, 2 but this is the natural 

1 A case of this kind was recently exhibited at a meeting of the Anatomical 
Society of Paris. Bulletin de la Soc. Anat. de Paris, 2d serie, t. iv., p. 2. 

2 Gaussail's statistics relative to the discharge are as follows : In 67 of 73 cases, 
the discharge and the other symptoms of the gonorrhoea had diminished more or 
less — in other words, the acute stage of clap had passed — when the swelling of the 
testicle took place ; in 6 cases, the gonorrhoea was still at its height. 

In 30 of the 73 cases, the discharge gradually diminished and disappeared entirely 
.luring the treatment of the epididymitis ; in 43 cases, some discharge remained 
after the disease of the testicle was cured. 



uo 



SWELLED TESTICLE. 



Fig. 4. 



course of the disease when no complication whatever takes place. 
To prove a metastatic origin of the epididymitis, it would be neces- 
sary to show that there is a sudden disappearance or diminution of 
the running, just preceding the swelling of the testicle ; such, how- 
ever, does not occur. On the contrary, as stated by Kicord, there is 
often an exacerbation of the urethral disease and a slight increase of 

the discharge for a day or two pre- 
ceding. When the disease of the tes- 
ticle is fairly established, the discharge 
diminishes as a consequence of revul- 
sive action. These phenomena coin- 
cide with what is seen in affections of 
other parts when acute inflammation 
is established in their neighborhood. 

The induration of the epididymis, 
which frequently remains for some 
time after an attack of swelled testicle, 
or which may even become permanent, 
requires further mention. This indu- 
ration is commonly situated in the 
lower part of the epididymis, in or 
near the globus minor. It will be 
recollected that the upper portion, 01 
globus major, is composed of the con 
volutions of the vasa efferentia, which 
are from ten to thirty in number, but 
that these minute vessels unite into a 
single duct, before leaving this portion. 
Hence the globus major of the epididymis consists of several semi- 
niferous tubes, any one of which would be sufficient to convey the 
semen, in case the others were obstructed; while the body and globus 
minor contain but one tube, the obliteration of which must com- 
pletely cut off the communication between the testis and the penis. 
But it is in this latter portion, viz., the globus minor, that the indu- 
ration left by an attack of swelled testicle is almost invariably 
found ; and, as we shall presently see, it generally effects the oblit- 
eration of the single duct of the part, and renders the patient 
impotent upon the affected side. 

It now becomes an interesting subject of inquiry, what effect this 
obliteration has upon the testis, whether it becomes atrophied, or 
whether it remains in a normal condition, and continues to secrete 
sperm Again, in those cases in which epididymitis has occurred 




Vertical section of the testis and epi 
didymis. (After Ghay.) 



SYMPTOMS. 141 

on both sides, an induration may be left in each testicle, totally ob- 
structing the passage of semen ; in such cases does the patient still 
retain sexual desires ; is he capable of sexual intercourse ; and if 
so, how does his semen differ from that of a perfectly healthy indi- 
vidual ? These questions have been ably answered in a paper by 
Dr. L. Grosselin, published in the Archives Generates de Medicine, for 
Sept. 1853. 

Dr. Grosselin's conclusions are based upon experiments upon the 
lower animals, and upon the observation of nineteen patients affected 
with double induration of the epididymis following gonorrhoea. The 
spermatic cord of one side was exposed in two dogs, the vas deferens 
isolated from the spermatic vessels, and a portion of it excised. The 
animals were killed several months after, when it was found that the 
testicle of the side operated on presented the same volume, color, and 
general character as that of the opposite side; the only difference 
was that the convolutions of the epididymis in the former were dis- 
tended with fluid, containing a multitude of spermatozoa. The ex- 
cision of a portion of the vas deferens had completely cut off the 
communication with the penis. These experiments proved that iso- 
lation of the testicle in the lower animals does not produce atrophy 
of this organ, which remains in an apparently healthy condition, and 
continues to secrete semen. 

The nineteen persons who had had double epididymitis were met 
with at the Hopital du Midi, and in the private practice of Dr. Gos- 
selin. The time which had elapsed since the formation of the indu- 
ration, at the time of the observation, varied from a few weeks to ten 
years. The symptoms which they presented were in some respects 
singular and remarkable. In all of them there was a mass of indu- 
ration in the lower portion of the epididymis of each testicle. In 
none of them was there any apparent change in the volume of the 
scrotal organs, and no pain was felt at any time, not even after sexual 
intercourse. None of them had observed any change in their sexual 
desires or powers. They were all as capable of coitus as the most 
healthy individuals. Their erections and ejaculations were complete. 
Their semen was normal in quantity, in consistency, in odor, and' 
color ; it presented the chemical reactions described by Berzelius, as 
characteristic of sperm. Only when examined by the microscope, 
was it found to differ at all from healthy semen, inasmuch as it was 
entirely destitute of spermatozoa. In the recent cases, most of which 
were still affected with urethritis, pus and blood-globules were found 
mixed with the semen ; in the older cases, these were absent. The 



14:2 SWELLED TESTICLE. 

entire absence of spermatozoa in all of them was confirmed upon 
repeated examination by Drs. Gosselin, Robin, Yerneuil, and other 
eminent Parisian microscopists. In two of these cases, treatment, 
continued in the one case for three months, and in the other for nine, 
resulted in the disappearance of the induration in one of the testicles, 
and coincidently with this resolution spermatozoa again appeared in 
the semen, as shown by microscopical examination. 

These cases are of the highest interest, looking at them both in 
the light of physiology, and of pathology and therapeutics. They 
show, in the first place, that the quantity of fluid ejaculated is as 
abundant and presents the same general appearances when the canal 
of the vas deferens is obliterated as when it is free ; also, that in case 
of obliteration, the secretion of sperm in the testis is not sufficient to 
distend the vessels to any great extent, or to occasion pain. Prob- 
ably there is some absorption of the secreted sperm, but if as much 
of this fluid were secreted by the testicles as is commonly supposed, 
the effect upon the testicular vessels and upon the feelings of the 
patient would be more manifest. From these facts Dr. Gosselin con- 
cludes that the normal function of the testicle is to furnish the fecun- 
dating element of the sperm, viz., the spermatozoa ; and that the 
other components of the spermatic fluid, to which it owes its color, 
odor and chemical reactions, and which constitute the medium in 
which the spermatozoa live, are derived for the most part from the 
vesiculae seminales. 

But the conclusions from these facts which chiefly interest us at 
the present time are those bearing on the pathology and treatment 
of epididymitis. These conclusions, as stated by Dr. Gosselin, are 
the following: — 

1. The induration is generally situated in the globus minor of the 
epididymis, though it may, strictly speaking, be seated in any part 
of this organ Since the epididymis below the globus major is 
composed of but a single vessel, the obliteration of this vessel is 
sufficient to prevent the passage of the sperm. 

2. The presence of the induration excites no pain, provided that 
the inflammation which produced it has entirely subsided. 

3. It does not occasion any change, appreciable by the patient, in 
the exercise of the genital functions. 

4. If the spermatic vessel be obliterated on both sides, the patient 
is necessarily impotent ; if on one only, fecundation is possible, pro- 
vided that the other testicle is sound. 

5. The success of treatment in several of the cases reported 



SYMPTOMS. 143 

• 

affords assurance that the power of fecundation may sometimes be 
restored by appropriate remedies. 

M. Godard states that he has confirmed Gosselin's observations 
by microscopical examination of the semen of more than thirty 
persons affected with double chronic epididymitis ; and in every 
instance spermatozoa were wanting. 1 

If gonorrhoeal epididymitis attack a testicle which has been 
arrested in its descent from the abdomen to the scrotum, the nature 
of the case may readily be mistaken. If the testis have not left the 
abdominal cavity, it may simulate peritonitis or iliac abscess ; if it 
be arrested in the spermatic canal, it may counterfeit strangulated 
hernia or bubo ; and the* liability to error is especially great, when, 
as often occurs, the tunica vaginalis is still connected with the abdo- 
minal cavity, and true peritonitis is set up by extension of the 
inflammation, attended by its usual alarming symptoms. Numerous 
cases in illustration of these remarks may be found in the work of 
M. Godard before referred to. 

A still rarer abnormal position of the testicle is in the perineum ; 
an anomaly first observed by John Hunter, who met with two cases. 
"Many years ago, a little boy, one of whose testicles had thus 
deviated from its proper course, was brought to the London Hospital. 
The gland was lodged in the perineum at the root of the scrotum." 2 
Eicord and Vidal 3 (de Cassis) have each observed two cases; Mr. 
Ledwich 4 met with one in a dissecting-room subject, and Godard 5 
gives the history of another, with a plate of the abnormity. These 
nine cases are all with which I am acquainted. A perineal testicle 
affected with gonorrhoeal epididymitis may simulate a perineal 
abscess or inflammation of Cowper's glands, as in the two instances 
observed by Eicord. 6 "In one, there was a perineal tumor, which 
was exquisitely painful, fluctuating and about the size of a pigeon's 
egg. It was at first taken for an abscess, and Eicord was about to 
open it, when examination of the scrotum led to the discovery that 
one testicle was absent." 

There is another consideration connected with abnormal position 
of the testicle, which is worthy of mention. In most cases of this 

1 Etudes sur la Monorchidie et la Cryptorchidie chez 1' Homme; extrait ies Md- 
moires de la Soc. de Biologie, anne"e 1856, Paris, 1857, p. 105. 

2 Curling, op. cit., p. 46. 

8 Traite" de Pathologie Externe, t. 5, p. 432. 

* Dublin Quart. Journ. of Med. Sci., Feb., 1855. 

5 Op. cit., page 65, and Plate III. 

6 Godard, op. cit., p. 96. 



144 SWELLED TESTICLE. 

anomaly, the gland is useless for the purposes of procreation. 
According to Goubaux and Follin, 1 it undergoes fibrous or fatty 
degeneration. This is denied by Godard, who, however, has equally 
shown that the gland, as a general rule, is impotent, by microscopical 
examination of the contained sperm after death. In eight cases out 
of nine, spermatozoa were wanting. Now, if the anomaly be con- 
fined to one side, and the opposite testicle be in a healthy condition, 
fecundaticfn is still possible ; but if the descended testicle be attacked 
by epididymitis, obliteration of its vas deferens will deprive the 
patient of all procreative power, as in the cases of double epididy- 
mitis observed by Gosselin. Godard gives the history of a man 
with one undescended testis, who had a child by a mistress, but who, 
after an attack of swelled testicle on the opposite side, was twice 
married without progeny, and his semen, twenty-one years after- 
wards, was found destitute of spermatozoa. 

Pathological Anatomy. — Since epididymitis, when uncompli- 
cated, is never fatal, opportunities for post-mortem examination are 
rare, and only occur in case some intercurrent disease produce the 
death of the patient. The most complete report of such examina- 
tion with which I am acquainted, is to be found in the Gazette des 
Hopitaux, for Dec. 21, 1854. 

Case. — The patient entered Velpeau's wards at la Charite with 
swelled testicle, of eight days' duration ; the epididymis was situated 
in front of the testicle, and was swollen and hard ) the cord was also 
involved, while the body of the testicle appeared to be sound, and 
there was no effusion in the tunica vaginalis 

Eighteen days after his admission, and twenty-six after the com- 
mencement of his attack, this patient died of cholera. The post- 
mortem was made by M. Gosselin, with the following result : — 

1. The tunica vaginalis contained no fluid and was free from injec- 
tion of its vessels. 

2. The body of the testicle was healthy. 

3. The globus major and the body of the epididymis were also 
healthy; but the globus minor was swollen and formed a hard, 
uniform mass, the size of a haricot bean. On cutting open this mass, 
it was found to be destitute of bloodvessels, of a uniform yellow 
color, resembling tubercle, and of firm consistency. The sections of 
the convoluted spermatic duct upon the cut surface showed that this 

i Follin, Etudes Anatomiques et Pathologiques sur les Anomalies de Position et 
les Atrophies du Testicule; Arch, de M6d., Juillet, 1851, p. 262. 

Goubaitx et Follin, De la Cryptorchidie chez l'Homme et les Principalis Animaux 
Domestiques; M6in. de la Soc. de Bilog., 1855, p. 317. 



. PATHOLOGICAL ANATOMY. 145 

vessel had attained three or four times its natural size, and, instead 
of being hollow, that it was filled with uniform yellow matter ; there was 
none of this matter between the convoluted vessels : it was entirely within, 
and in the substance of the walls. M. Eobin examined this matter under 
the microscope and found pus-globules, mixed with fat-globules and 
the granular globules of inflammation. He also confirmed the state- 
ment that this matter was limited to the interior of the vessels. 

4. The vas deferens, which had recovered its normal size, was filled 
with yellowish matter, containing no spermatozoa, and composed of 
pus-globules, cylindrical epithelial cells, and granular corpuscles. Its 
walls exhibited a perfectly normal appearance. 

5. The vesicula seminalis on the affected side was healthy. It con- 
tained a small amount of fluid, with pus-globules and epithelial cells, 
but no spermatozoa. Spermatozoa were found in the vesicula semi- 
nalis on the opposite side. 

M. Gaussail (Arch. Gen. de Med., 1831, torn, xxvii., p. 188,) has 
also reported two cases of post-mortem examination of swelled 
testicle, in which, however, the examination was made with less 
care than in the case just quoted. 

Mr. Curling (op. cit., p. 209) says that he has twice had the oppor- 
tunity of making a post-mortem examination of swelled testicle, 
lmt gives no account of the appearances presented. Mr. Brodie 1 
examined the body of a gentleman who had had gonorrhoeal epi- 
didymitis twenty years before, and found the testicle smaller than 
natural and " one-third of the tubuli testis converted into a white 
substance, having the consistence, but not the fibrous structure, of 
ligament." 

The first case which I have quoted as occurring in the service of 
M. Yelpeau, is, I believe, the only one on record, in which the 
examination has been made with all the light which modern science 
affords, and I would especially call attention to the fact that the 
fibrinous deposit was found to. be situated within the vessel of the 
epididymis and not between the convolutions. This fact is in oppo- 
sition to the statement of Mr. Curling ; but it can hardly be called 
in question in the case here reported, and it strongly favors the 
opinion of M. Grosselin that the communication between the testis 
and the penis is almost invariably obstructed during an acute attack 
of epididymitis, and also during the continuance of the induration 
which is often left behind. I would not be understood as asserting, 
however, that the exudation is always confined to the interior of 

1 Clinical Lecture on Diseases of the Testis; London Medical Gazette,, vol.. siii., 
p 219, 1834. 

10 



146 SWELLED TESTICLE. 

the vessel ; it may also involve the areolar tissue connecting the 
convolutions, but its deposit in the former situation appears to be 
the more persistent, and the more important so far as the procreative 
powers of the patient are concerned. 

The pathological changes produced by epididymitis can only be 
studied to advantage in recent cases. In the masses of induration 
which have existed for months or years, the anatomical elements 
are so confounded that it is impossible to distinguish them. 

Treatment. — The treatment of gonorrhceal epididymitis should 
be decidedly antiphlogistic. It is indeed true that under temporizing 
measures, the inflammation will subside in time, but an effusion of 
plastic lymph, endangering the procreative powers of the patient, 
will be more likely to occur, than when the case is treated actively 
at the outset. 

Eest in the horizontal posture, even if the feelings of the patient 
do not demand it, should be strictly insisted on. As the patient 
lies in bed upon his back, the scrotal organs should be supported 
by a number of folded towels, placed between the thighs, or by a 
folded handkerchief arranged around them like a sling, with its ends 
attached to a bandage round the waist. I usually order an emetico- 
cathartic, as in the following prescription : — 

R. Antimonii tartarizati gr. iv. 

Magnesise sulphatis ^iss. 

Aquae camphorae ^vj. 
M. 

I direct the patient to take a tablespoonful of this mixture every 
twenty minutes or half hour, until free vomiting has been excited, 
and then repeat the same quantity every few hours, or sufficiently 
often to keep him slightly nauseated and to produce a number of 
evacuations from the bowels during the day. If the case be at all 
severe, the application of leeches should not be omitted. It is better 
to apply them over the cord, directly below the external abdominal 
ring, rather than upon the scrotum. They thus deplete the part 
even more directly than in the latter situation, and any irritation 
from their bites is avoided. Their number should vary from four 
to ten, according to the, severity of the case. They rarely fail to 
afford great relief to the pain, although the swelling may not dimin- 
ish or may even increase ; in some cases, however, they require to 
be repeated in twenty-four or forty-eight hours, or after the lapse of 
a few days, in case the symptoms, after once subsiding, again become 
aggravated. In the absence of leeches, blood may be drawn from 



TREATMENT. 147 

several of tlie scrotal veins. The patient should stand up, and the 
parts be bathed with hot water until the veins are well distended, 
when they may be opened with a lancet. When a sufficient quantit j 
of blood has been drawn, the patient should again lie down and the 
flow of blood will usually cease in a short time ; or, if excessive, it 
may be arrested by compression with serves fines, ordinary forceps, or 
by one of the haemostatics. 

Both cold and hot local applications have been recommended in 
this disease. Judging from my own experience, the former, when 
applied at the outset, will often succeed in arresting the progress of 
the inflammation; but when the disease is fairly established, the 
latter are more grateful to the patient and more effectual in hasten- 
ing resolution. If called sufficiently early, I usually order half an 
ounce of muriate of ammonia to be dissolved in a pint of water, and 
direct the patient to keep a single thickness of cloth wet with this 
lotion applied to the scrotum. Simple cold water may be used in 
place of the solution of muriate of ammonia, although I consider 
the latter preferable. The bedclothes should be kept elevated, so 
that evaporation may be free and the temperature of the part reduced. 
In the course of a few hours, ice may gradually be added to the solu- 
tion, with comfort and benefit to the patient, and his sensations may 
be taken as an index of the degree of cold required. At night, the 
frequent wetting of the cloths would prevent rest, and it is better, 
therefore, to remove them. Extract of belladonna, moistened with 
a little water, and smeared over the scrotum, may now take the place 
of the lotion, and will ease the pain and favor sleep. The internal 
administration of an opiate may also be required. 

If cold applications are not well supported, or if, in spite of our 
efforts, the pain and swelling increase, poultices of bread and hot 
water, or linseed meal, should be substituted for the cold lotion ; or 
in robust subjects, poultices of tobacco leaves may be employed for 
the purpose of obtaining the nauseating and sedative effect of this 
narcotic. 

If at any time in the course of the treatment we have reason to 
suppose there is a collection of fluid in the tunica vaginalis, it is best 
to evacuate it. Yelpeau directs, in performing this operation, that 
the tumor should be rendered tense by grasping it posteriorly as in 
the operation for hydrocele, and that the lancet, plunged into the 
cavity of the tunica vaginalis, should be retained in the wound, and 
gently twisted on its axis, in order to preserve the parallelism of the 
incisions in the skin and mucous membranes, until all the fluid 
escapes. I have not found this latter precaution necessary. When 



148 SWELLED TESTICLE. 

a broad lancet is used the wound is sufficiently patent, and the paral- 
lelism of the incisions is preserved by retaining the hold on the scro- 
tum posteriorly; indeed the fluid escapes more freely with the 
instrument withdrawn. 

I have found the results of the above method of treatment very 
satisfactory. Eesolution generally commences within 24 or 36 hours, 
and the patient is rarely confined to his room longer than five days, 
or a week. 

When the swelling has been somewhat reduced and the pain dis- 
sipated, and the parts will bear gentle handling, resolution may be 
hastened by the application of strips of adhesive plaster so as to 
exercise compression upon the testis. This method of treatment was 
first suggested by Dr. Fricke, of Hamburg, and is known by his 
name. 1 It is not to be used until the acute symptoms have subsided, 
nor while the spermatic cord is much engorged, nor if there is reason 
to fear the formation of an abscess in the testicle or subscrotal cellu- 
lar tissue. The objections which have been urged against this 
method have been founded upon its indiscriminate use. The feel- 
ings of the patient after the straps are applied will indicate whether 
they should be continued or not. If applied at the proper stage of 
the disease, they will afford a sensation of support and relief; should 
they increase the pain, they are doing harm and ought to be at once 
removed. 

A mixture of two parts of adhesive plaster with . one part of 
extract of belladonna spread upon thin leather, is more elegant, 
and, in many respects, better than adhesive plaster alone. It is 
softer, more elastic, less likely to chafe the skin about the cord, is 
removed with greater facility and ease to the patient, owing to its 
adhering less firmly to the skin and hairs, and, moreover, the bella- 
donna acts powerfully as a sedative. 

Before applying the plaster, the hair should be carefully removed 
from the scrotum with a razor or scissors. The plaster is to be cut 
into strips about three-quarters of an inch in width. The testicle is 
now to be pressed down to the lower portion of the sac and held 
there by the thumb and forefinger of the left hand, while a strip is 
placed firmly round the affected side of the scrotum, just below the 
abdominal ring. Successive strips are added, each one overlapping 
the preceding for one-third its width, and care being taken that they 
all fit smoothly, until all but the bottom of the testicle is enveloped ; 

1 Dr. Frickk's paper was published in the Zeitschrift fur die gesammte Medicin. 
h. j. h. 1. Hamburg, 1836. A translation of it appeared in the British and Foreign 
Medical Review, vol. ii. 1836, p. 258. 



TREATMENT. 149 

the latter should then be covered with strips applied longitudinally, 
like the bottom of a wicker basket, and finally, the whole is to be 
secured by a long narrow strip carried circularly several times 
around the tumor. In the course of from twelve to twenty-four 
hours, the plaster will be found to be loosened by the decrease of 
the swelling, when it should be removed and fresh strips applied. 
The compression should be continued until the testis has nearly 
returned to its normal dimensions, and in the meantime the parts 
still be supported by a bandage. 

When the patient can be kept quiet, strapping the testicle may 
commonly be dispensed with. Cullerier states that it has been 
entirely abandoned in France. 

The application of collodion to the scrotum as a means of com- 
pression, suggested by M. Bonnafont, was a subject of discussion 
before the Academy of Medicine in Paris, in 1854, and a trial was 
made of it by Bicord and others, who reported against it. 

In those cases in which, after the subsidence of the acute symp- 
toms, the testicle remains in a condition of chronic engorgement, it 
is not best to persevere in an antiphlogistic course of treatment. 
The diet should be nourishing, but not stimulant. Any effusion 
into the tunica vaginalis should be evacuated and the scrotal organs 
carefully strapped! The bowels should be kept free, and marked 
benefit will be derived from small doses of mercurials, as, for in- 
stance, a few grains of blue mass administered every night at 
bedtime. 

Opinions as to the propriety of treating the urethritis during an 
attack of swelled testicle have been widely different. Those who 
believe in the metastatic origin of epididymitis, have not only 
refused to take measures to cure the urethral discharge while the 
testicle was still inflamed, but have even advised that the urethra 
should be irritated by bougies or otherwise, so as to recall the dis- 
ease to its original seat. Such practice is founded on a false assump 
tion, and is both useless and dangerous. The continuance of the 
urethritis can only aggravate the epididymitis, or tend to produce a 
relapse if it has already subsided. The cure of the urethral dis- 
charge can alone afford security for the future. This, however, is 
not to be attempted by irritant injections. I am in the habit of 
employing the injection of glycerin, extract of opium, and sulphate 
of zinc, which I have recommended in the acute stage of gonorrhoea, 
never, however, adding a sufficient quantity of the sulphate to excite 
more than a momentary prickling sensation in the canal. The fol- 
lowing formula is generally applicable : — 



150 SWELLED TESTICLE. 

R. Extracti opii ^j. 

Glycerin *j. 

Zinci sulpkatis gr. vj-xij. 

Aquae ^vj 
M. 

Copaiba and cubebs have no curative action upon epididymitis, 
and I think it best to abstain from using them when this complica- 
tion supervenes. 

There are two other modes of treating gonorrhoeal epididymitis 
which require notice. The first is that proposed by M. Velpeau, 
and consists in puncturing the tunica vaginalis and evacuating the 
contained fluid, no matter how small its quantity. This procedure 
has already been recommended above, when the fluid has attained 
an appreciable amount. The peculiarity of M. Velpeau's practice 
lies in the frequency with which he employs it, even where a few 
drops only escape from the incisions. He claims for this method 
that it gives immediate relief to the pain, that it shortens the dura- 
tion of the disease, and takes the place of leeches and other trouble- 
some and expensive remedies. Cullerier also accords high praise 
to this practice. The dread of the knife which patients laboring 
under this disease naturally have, is a strong objection to its frequent 
employment. As a general rule, it is safe, for in one case only, so 
far as I am aware, has it been attended with any unpleasant result. 
This was a patient under the care of M. Montanier, 1 in whom exces- 
sive hemorrhage followed a simple incision into the tunica vaginalis, 
which was very difficult to control, and which even endangered life. 
Probably some scrotal artery of considerable size was wounded in 
the operation. 

The late M. Vidal (de Cassis) revived an operation which is said 
to have originated with a French surgeon by the name of Petit, who 
published a work on venereal in 1812. This operation is simply an 
extension into the substance of the testicle of the incisions recom- 
mended by Yelpeau. Vidal states that he first employed these 
incisions in swelled testicle when the body of the testicle was 
involved, to which form of the disease he gives the name of paren- 
chymatous orchitis. His design was, by dividing the tunica albu- 
ginea to relieve the constriction exercised by this fibrous tunic 
upon its inflamed contents. Finding, as he says, that the operation 
was unattended by any unpleasant result, and that it relieved the 
pain and hastened resolution, he extended it to the more frequent 
cases in which the epididymis is alone attacked, and found the effect 

1 See the Gaz. des Hopitaux, 1858, p. 10b*. 



TREATMENT. 151 

equally favorable. In his work on venereal, this author states that 
he has performed this operation with impunity in four hundred 
cases, and claims for it preference to all other modes of treatment. 
His directions as to the manner of performing it, are to incise the 
tunica albuginea with a bistoury or lancet passed through the scro 
turn and tunica vaginalis to the extent of six-tenths of an inch (un 
centimetre et demi), and to penetrate the parenchyma of the testicle 
to the depth of less than three-tenths of an inch (de moins de moitie). 
Only one puncture of this kind is to be made. In spite of M. 
Vidal's testimony in its favor, we can hardly believe this operation 
entirely devoid of danger, especially since the recent report of four 
cases observed by a single surgeon, M. Demarquay, in which the 
substance of the testicle gradually oozed from the incision in fila- 
ments, and in three of which the testicle was totally lost. 1 If resorted 
to at all, it should probably be reserved for those cases in which 
it was first used, viz., where the body of the testicle is extensively 
implicated. 

Numerous other topical remedies have been recommended in gon- 
orrhoeal epididymitis, but many of them are not worthy of mention. 
Inunctions of mercurial ointment upon the scrotum may relieve the 
pain, but are liable to cause salivation. They may be used with 
caution in those cases in which the acute symptoms have subsided, 
leaving chronic engorgement of the epididymis. The application 
of chloroform has been advised, but before affording ease it usually 
increases the pain and renders it almost insupportable. ' 

The active treatment by leeches and purgatives, above recom- 
mended during the acute stage of epididymitis, includes the best 
prophylactic measures that we can adopt to prevent any induration 
being left behind in the epididymis. If such be detected, however, 
the earlier it is attacked the better, for the chances of success are 
certainly superior, while the plastic material is not yet fully organ- 
ized. If the indurated epididymis is still abnormally sensitive to 
pressure, the application of a few leeches over the cord, repeated 
several times at intervals of a few days, will be found of service. A 
small quantity of mercurial ointment should be rubbed into the 
scrotum morning and night ; the genital organs should be well sup- 
ported by a suspensory bandage, and the bowels be kept free. Much 
is to be expected also from the internal administration of iodide of 
potassium, which is so powerful an agent in resolving inflammatory 

1 British and For. Medico-Chirurg. Rev., Am. ed., Apr. 1859, from the Bulletin de 
Therapeutique, tomelv.,p. 549. 



152 SWELLED TESTICLE. 

products generally. It is impossible to say how old an induration 
of the epididymis can be treated with hopes of success. M. Gos- 
selin's cases show that it may disappear after existing for several 
months, and it is not improbable that a cure may be effected after a 
much longer period. Where the epididymis on both sides is 
affected, the attempt should certainly be made, especially if the 
patient is young and intends to marry. It is a serious question 
whether the surgeon should inform him of the impotency which his 
disease entails, since the effect upon his mind might possibly be 
most disastrous. 



INFLAMMATION OF THE PROSTATE. 153 



CHAPTER VII. 

INFLAMMATION OF THE PROSTATE. 

ACUTE PROSTATITIS. 

Acute prostatitis may be due to violence from sounds, catheters, 
or lithotrity instruments ; to the application of caustic to the deeper 
portions of the urethra ; to stricture, the irritation of a stone in the 
bladder, immoderate coitus, or excessive purgation ; but by far the 
most frequent cause is urethral gonorrhoea. 

Gonorrhoeal prostatitis owes its origin to the extension of the 
inflammation from the urethral walls to the substance of the prostate 
gland ; it occurs, therefore, at a time when the disease has invaded 
the deeper portions of the canal, and is consequently rare during the 
first two weeks of a gonorrhoea ; resembling in this respect its more 
frequent congener, gonorrhoeal epididymitis. The accessory causes 
of the last mentioned disease, viz., highly irritant injections, forcible 
distention of the urethra in using a syringe, excessive exercise, alco- 
holic stimulants, exposure to cold and wet, and venery, may also 
contribute to the production of prostatitis. There is less ground for 
believing that this affection is occasioned by the use of copaiba and 
cubebs, unless in very immoderate doses. 

The earliest symptom of an attack of prostatitis is commonly a 
sensation of weight or a dull pain in the perineum. There is not 
that vesical tenesmus which we find in cystitis, but the exit of the 
urine may be obstructed by the swollen gland, when the calls tc 
micturate will be frequent and urgent simply because the bladder is 
never fully emptied of its contents, and a short time suffices to fill 
it to distention. The stream is generally quite small, is only forced 
out by prolonged straining, and excites a severe scalding sensation 
in the deeper portion of the canal. Complete retention of urine 
often occurs, requiring the use of the catheter. The bowels are com- 
monly constipated, although the patient is constantly led by a feeling 
of fullness in the rectum to make fruitless efforts at stool ; and should 
defecation take place, the act excites severe pain. The system at 



154 INFLAMMATION OF THE PKOSTATE. 

large sympathises with the local trouble, and general febrile excite- 
ment ensues. Exploration of the prostate by the finger in the rec- 
tum reveals abnormal sensibility and tumefaction of this organ pro- 
portioned to the severity of the disease ; and a sound introduced 
into the urethra, upon reaching the prostatic region, meets with an 
obstruction and excites a degree of suffering that is with difficulty 
endured by the patient. 

Acute prostatitis may terminate in resolution, in suppuration, and, 
in rare instances, in gangrene. Several cases are recorded in which 
the inflammation has extended to the peritoneum, and in which 
death has ensued from peritonitis. 

Of the above modes of termination, suppuration, next to resolu- 
tion, is the most frequent. The formation of matter is not always 
announced by well-marked symptoms, but may be strongly sus- 
pected if, after the disease has been increasing in intensity for eight 
or ten days', the patient is seized with repeated chills followed by 
fever and general depression. It is possible, however, for an abscess 
to form without affording the least reason to suspect it. A case 
recently occurred at St. George's Hospital under the care of Dr. 
Pitman, in which prostatitis supervened upon an attack of gonor- 
rhoea, and terminated in suppuration and the death of the patient, 
with entire absence of rigors and the ordinary symptoms of abscess 
of the prostate. At the post-mortem examination, an extensive ab- 
scess, which had not been suspected during life, was found between 
the bladder and rectum. 1 

The abscess may be situated between the rectum and the gland, in 
the substance of the latter, or upon its urethral aspect. In the first 
two instances, a soft fluctuating tumor can be felt in the region of 
the prostate by the finger introduced into the rectum, especially if 
the gland be immovably fixed by a sound in the urethra. An ab- 
scess in the neighborhood of the urethra is more difficult of detec- 
tion, except from its encroachment upon the canal, and its inter- 
ference with the exit of urine and the introduction of a catheter. 

A prostatic abscess most frequently breaks upon the side of the 
urethra during the efforts of the patient to expel the urine or feces, 
or it is often perforated by the point of an instrument introduced 
for the purpose of exploration or catheterization ; sometimes it opens 
into the rectum, bladder, or cellular tissue of the pelvis ; or it may 
communicate with both bladder and rectum and give rise to a uri- 
narv fistula. In other instances the fluid contents are absorbed, and 

1 London Lancet, Am. ed., Jan. 1861, p. 69. 



DIAGNOSIS — TREATMENT. 155 

the abscess becomes surrounded by a kind of cyst which is filled 
with a semi-solid substance resembling a deposit of tubercle. 

Diagnosis. — Acute prostatitis is chiefly liable to be confounded 
with cystitis, from which it may generally be distinguished by the 
following characters : — ■ 

1. By the greater degree of constitutional disturbance; general 
febrile reaction being a much more frequent attendant of inflamma- 
tion of the prostate than of the bladder. 

2. The pain in prostatitis is more of a throbbing and bearing- 
down character, is chiefly confined to the perineum, and is less 
prone to radiate to the extremity of the penis and elsewhere than 
the pain of cystitis. 

The chief means, however, of distinguishing these two diseases 
is to be found in physical exploration. 

3. In prostatitis, the finger introduced per anum will detect the 
swollen and sensitive gland encroaching upon the rectum, and ex- 
tending in some instances higher than the point of the finger can 
reach. In cystitis, the introduction of the finger within the anus 
may be painful in consequence of the inflammation extending to 
the recto-vesical wall, but no tumor can be felt. 

4. In prostatitis, the passage of a catheter is attended with great 
pain and meets with obstruction in the prostatic portion of the 
urethra ; and when it enters the bladder, a large amount of urine 
escapes. In cystitis, there may be some obstruction to catheterism, 
but this is situated at the vesical neck, and the bladder is found to 
be nearly empty of urine, since the extreme irritability of its walls 
does not permit any large collection. 

Treatment. — The appearance, during an attack of gonorrhoea, 
of symptoms of prostatitis, should lead the surgeon at once to 
abandon the use of injections; and, neglecting the urethral dis- 
charge for a time, to direct his whole attention to the more serious 
affection which has supervened. The patient should now observe 
the most perfect rest and quietude. If the symptoms be at all 
severe, from six to a dozen leeches should be applied to the peri- 
neum, and be followed by a hot bath at the temperature of 1 00°, 
which may be repeated with benefit several times in the twenty-four 
hours. Some authors recommend the application of leeches by 
means of an anal speculum to the anterior wall of the rectum, 
where contiguous to the inflamed gland. In the intervals of the 



156 CHR0XIC PROSTATITIS. 

baths the perineum should be covered with hot fomentations or 
poultices. 

Internally we may resort to those remedies, as the salts of potash 
and soda, which are supposed to render the urine more dilute and 
mild in its character. The formula containing mucilage, bicarbonate 
of potash, and hyoscyamus, already given in the chapter upon ure- 
thral gonorrhoea in the male, is well adapted for the treatment of 
the disease we are now considering. The diet should be abstemious, 
consisting of gruel, mucilaginous drinks, milk, and farinaceous 
substances, at least in the early stages of the disease; at a more 
advanced period, and after suppuration has taken place, our utmost 
efforts may be required to sustain the strength of the patient by a 
nourishing diet and even tonics. 

Sleep should be secured by the exhibition of a Dover's powder at 
night. Mr. Adams speaks highly of warm enemata, consisting of 
four or five ounces of simple water or gruel, administered at bed- 
time, which are said to afford comfort to the patient, and to act as a 
fomentation to the inflamed gland. 1 

Complete retention of urine will require evacuation of the bladder 
by means of a catheter. When an abscess has formed and fluctua- 
tion can be distinctly felt by the finger in the rectum, it should be 
punctured through the intestinal wall ; or when the collection of 
matter is most prominent towards the urethra, it may sometimes be 
opened by a conical sound introduced as far as the prostatic portion 
of the canal, while a finger within the rectum presses the tumor 
against the point of the instrument. This attempt, however, is by 
no means free from danger, and should never be made, unless the 
symptoms are urgent and the existence of matter in the neighbor- 
hood of the urethra highly probable. 

CHRONIC PROSTATITIS. 

The preceding affection is that form of prostatitis which most 
frequently accompanies and originates in urethral gonorrhoea. 
Chronic prostatitis, on the contrary, is more commonly due to 
onanism, excessive venereal indulgence, or sedentary habits; and, 
although not unfrequently occurring in persons who have suffered 
from gonorrhoea, is in most cases less directly traceable to this 
affection. 

For a long period chronic prostatitis was confounded with irrita- 

1 Anatomy and Diseases of the Frostate, p. 41. 



CHRONIC PROSTATITIS. 157 

tion and inflammation of the neck of the bladder, and was not 
recognized as a distinct disease until the publication of the admirable 
descriptions of it by Mr. Adams, 1 Mr. Ledwich, 2 and more recently 
by our distinguished countryman, Dr. Gross, of Philadelphia. 3 

Chronic prostatitis is most common in young men, and especially 
among those who lead a sedentary life, or who are the victims of 
masturbation. It is also met with in persons who have abused 
their sexual powers either in promiscuous intercourse or early 
married life. 

One of the most frequent and prominent symptoms of this affec- 
tion is a discharge of clear and transparent, or sometimes turbid, 
mucus from the meatus, which is found by the microscope to consist 
of: 1. "Morphous crystals of uric acid, or ammoniaco-magnesian 
phosphates; 2. Mucus-corpuscles; 3. Blood-disks; and 4. Epithelium 
cells," 4 either with or without a few pus-corpuscles. The discharge 
may be almost constant in its appearance and sufficient in quantity 
to stain the linen, or, more frequently, it is forced from the urethra 
by the pressure of the hardened feces during straining at stool, and 
is not perceptible at any other time. Most patients suppose that it 
consists of semen, from which it may be distinguished under the 
microscope by the absence of spermatozoa. Very many of the cases 
of spermatorrhoea so-called are doubtless instances of this affection. 

In most cases, the frequency of micturition is more or less in- 
creased ; the stream of urine is ejected without force ; the last drops 
dribble away, or are only expelled with considerable effort ; and a 
scalding sensation is felt in the urethra during and after the act. 

Pain and uneasy sensations are experienced in the perineum, 
thighs and lumbo-sacral region ; there is often great irritation about 
the anus attended by haemorrhoids or eczema ; the bowels are con- 
stipated, and defecation difficult and painful;" the passage of an 
instrument into the bladder excites severe pain as it passes through 
the prostatic region ; on examination per anum, the gland is found 
to be tumefied, sensitive on pressure, and sometimes indurated ; the 
patient is irritable and low spirited ; is incapable of mental or phy 

1 Anatomy and Diseases of the Prostate Gland. London, 1853. 

2 Dublin Quarterly Journal, Aug. 1857, p. 30. 

3 North Am. Med.-Chir. Rev., July, 1860. Dr. Gross describes this as a hitne/to 
unknown affection under the name of " prostatorrhoea," but his account of it cor- 
responds in almost every particular with that given by Mr. Adams under the head 
of "prostatitis from onanism." The increased secretion of prostatic fluid is a mere 
symptom of irritation or inflammation of the gland, and it is therefore desirable 
that the term prostatitis should be retained. 

4 Ledwich, op. cit. 



158 INFLAMMATION OF THE PROSTATE. 

sical exertion; suffers from weakness, headache, and dyspepsia; 
watches his symptoms with the greatest anxiety ; imagines that he 
is losing his memory, that he is impotent or affected with syphilis, 
and, in short, becomes a desperate hypochondriac. 

Independently of its action upon the nervous system, chronic 
prostatitis is not a serious, although a very obstinate disease. It 
never terminates in suppuration and abscess, nor in the chronic 
hypertrophy so common in old men. 

Mr. Ledwich has had an opportunity, in two instances, of becom- 
ing acquainted with the pathology of this affection; "one case 
occurred at the age of 18, the second at 30 ; both were well-marked 
examples of the disease, and succumbed to phthisis, but this latter 
had no connection with the urethral affection. The prostato-vesical 
plexus was full, and many of its branches varicose ; the capsule of 
the prostate adhered intimately to its surface, and, on slicing the 
gland, it seemed soft, with large, open, venous branches on the sec- 
tion, from which blood exuded, whilst the whole gland exhibited 
an augmented volume ; the mucous membrane of its urethral aspect 
was red, soft, thickened, and villous, whilst the ducts could be dis- 
tinguished with the unassisted eye ; the uvula and trigonum vesica? 
were red and turgid, but the remainder of the bladder was healthy. 
I examined with some anxiety for the presence of tubercular de- 
posit in the gland, but, although this morbid condition was often 
anticipated, no evidence of any such structural lesion could be 
detected. The seminal ducts did not present any alteration as to 
size, their excretory orifices being discovered with the greatest 
difficulty, the vesiculse seminales being full and swollen, but without 
any other abnormal appearance ; scrofulous tubercles existed in the 
epididymis, yet the testicles, although soft and small, were other- 
wise healthy." 

Treatment. — In most cases of chronic prostatitis, the patient is 
laboring under a combination of mental as well as physical symp- 
toms, and the treatment must be directed to the mind equally with 
the body. It is not sufficient in these cases to dash off a hurried 
prescription and dismiss the patient after five minutes' conversation. 
The victim of mental more than physical suffering has for weeks or 
even months been brooding over his complaint during all his waking 
moments, not absolutely necessary to his daily occupation, exagge- 
rating each trifling symptom, entertaining the most gloomy fore- 
bodings of the future, and perhaps contemplating suicide. First of 
all, he needs a friend who can lead him, however reluctantly, to 



TREATMENT. 159 

unburden his mind of its sorrow. This load removed, he at once 
feels lighter and more hopeful. The surgeon's first object, there- 
fore, should be to gain his confidence by friendly yet manly conver- 
sation, lending a ready ear to the familiar story of tne hypochondriac, 
encouraging him to feel that he has found a sympathizing friend aa 
well as physician, and gradually and skilfully leading him from the 
depths of despondency to more rational views of his position and 
prospects in life. 

One great source of anxiety to the patient is probably the idea 
that the transparent viscid discharge which appears during straining 
at stool, or is mingled with the last drops of urine, consists of semen. 
The surgeon is generally safe in assuring him of the contrary, 
without special examination, since diurnal spermatorrhoea without 
some degree of spasmodic action is exceedingly rare ; but any doubt 
upon the subject may be removed by placing a drop of the fluid 
under the microscope, which will probably confirm his assurance by 
showing the absence of spermatozoa. 

Most cases of chronic prostatitis require the administration of a 
tonic, as iron, of which the tincture of the chloride, in the dose of 
twenty drops after each meal, is one of the best preparations. I 
have also obtained favorable results from a solution of strychnine in 
dilute phosphoric acid : — 

R. Stryehnise gr. j. 

Acidi phosphorici diluti Jiij. 
M. 
A teaspoonful three times a day. 

Ergot, either alone or combined with camphor, is another remedy 
which may often be employed to advantage. 1 

The large proportion (about two-thirds) of muscular fibre entering 
into the composition of the prostate, explains why affections of this 
body are but slightly amenable to those remedies, as iodine, the 
action of which is so favorable upon organs strictly glandular. 

Chronic inflammation of the prostate is perpetuated by the con- 
stipated state of the bowels and consequent straining at stool which 
usually attends it, and which should, therefore, be obviated by laxa- 
tives or enemata; but aloes, which is a constituent cf most of our 
pharmaceutical preparations for this purpose, should be avoided, on 
account of its well-known tendency to produce congestion of the 
hemorrhoidal vessels. Saline cathartics may be administered in 

1 See an article by Dr. C. L. Mitchell, on Ergot in Spermatorrhoea, Congestion, 
and Irritation of the Genital Organs in the Male ; Am. Medical Monthly, April, 1861, 
p. 283. 



160 INFLAMMATION OF THE PROSTATE. 

small doses in the morning on rising ; but I much prefer enemata of 
cold water, taken immediately before the usual time of going to stool, 
which are followed by a loose evacuation unattended by straining, 
and which prevent the discharge of prostatic fluid. In cases compli- 
cated with gleet, and in the absence of acute inflammation, benefit 
may be derived from weak astringent urethral injections. 

As a general rule, local applications may be dispensed with, and 
are so far objectionable as they tend to direct the thoughts of the 
patient to the seat of his disease. Yet when decided tenderness of 
the prostate is found on examination per anum, the repeated appli- 
cation of leeches or blisters to the perineum will prove beneficial. 
The late Dr. J. C. Warren, of Boston, highly recommended in these 
cases the use of the cold douche to the perineum. Moderate sexual 
indulgence is found to relieve the morbid irritability of the genital 
organs, and matrimony, when practicable, should be recommended 
to those who are single. 



INFLAMMATION OF THE BLADDER. 161 



CHAPTER VIII. 

INFLAMMATION OF THE BLADDER. 

Cystitis is another complication of gonorrhoea, occurring as a 
consequence of the extension of the inflammation along the con- 
tinuous mucous surface common to the urethra and bladder. It has 
also been attributed in rare instances to the gonorrhoea! discharge 
finding its way, or being forced into the bladder, and there lighting 
up inflammation similar to that affecting the urethral walls. A case 
of this kind is reported in the Arch. Gen. de Medicine, 1 in which 
cystitis suddenly supervened after using a simple emollient injection. 
All those causes which aggravate the urethritis may concur in 
exciting cystitis, among which may be mentioned sexual intercourse, 
indulgence in alcoholic stimulants, including malt liquors, fatigue, 
and the use of highly irritant injections. Cystitis never occurs at 
the commencement of an attack of gonorrhoea, but usually towards 
its decline, after the disease has had time to invade the deeper por- 
tions of the urethra. 

Gonorrhoeal cystitis is almost always confined to the neck of the 
bladder. The first symptoms that attract the attention of the patient 
are a frequent desire to pass his urine, and a feeling of heaviness in 
the perineum, which is frequently accompanied by a tickling or 
itching sensation at the extremity of the penis. The urine is high 
colored, and deposits upon standing a more or less copious, stringy, 
and whitish sediment, composed chiefly of pus and mucus ; and the 
urethral discharge usually becomes more free and purulent. In the 
majority of cases, there is little or no febrile disturbance, the appe- 
tite is unimpaired, the patient sleeps well, except that he is called 
up several times in the night to pass his water, and feels on the 
whole about as well as usual. 

In other cases, the symptoms are much more severe ; there is 
decided pain in the perineum and across the hypogastric region 

1 Tome xiii.,p. 454, 1829. 
11 



162 . INFLAMMATION OF THE BLADDER. 

radiating to the head of the penis, the testicles, and the groins ; the 
desire to micturate recurs every few minutes, when only a very 
small quantity of dark-colored urine can with difficulty and pain be 
evacuated, followed sometimes by a few drops of pure blood, and 
usually by most distressing tenesmus at the vesical neck, which the 
patient endeavors to relieve by pressing upon the perineum with 
one hand, while with the other he pinches the extremity of the 
penis. In such cases, there is usually some degree of febrile disturb- 
ance, indicated by a frequent pulse, loss of appetite, anxiety of 
countenance, general depression, and intense thirst. Eetention of 
urine, which we have seen to be common in prostatitis, is rare in 
gonorrhceal cystitis ; but it occasionally occurs as a consequence of 
loss of contractility in the vesical walls, and the distended bladder 
can then be felt above the pubes. 

As stated by Lallemand, inflammation confined to the neck of 
the bladder may be recognized by the peculiar phenomena attend- 
ing catheterization. "In proportion as the instrument advances 
through the curved portion of the urethra, the pain of its introduc- 
tion increases, and, when it reaches the vesical neck, becomes intol- 
erable. The neck of the bladder closes as the catheter approaches 
and is pushed on before it ; so that the instrument may appear to 
have entered the bladder, but, if left to itself, is partially forced out 
of the canal by the restoration of the neck to its natural position. 
Under these circumstances nothing would be gained by using force, 
which, moreover, is capable of doing much harm. The catheter 
should be left in place until the spasmodic contraction has passed 
off; when the vesical neck opens of itself and appears to draw the 
point of the instrument into the bladder by a kind of suction pro- 
cess accompanied by a slight to-and-fro movement. The pain at 
this time is especially severe; it appears to the patient as if the 
catheter weie touching a raw surface ; and considerable difficulty is 
experienced in withdrawing the instrument, owing to the contraction 
of the vesical neck around it." 

In the exceptional cases in which the las-fond of the organ is 
involved, there is frequent desire to go to stool and rectal tenesmus ■ 
severe inflammation of the recto-vesical septum may ensue, render- 
ing the introduction of the finger or an enema-tube within the anus 
extremely painful ; while in some instances the valvular outlets of 
the ureters are closed by the tumefaction of the vesical walls, o-ivino- 
rise to distention and dilatation of the ureters. In rare instances as 
noticed by Sir Benjamin Bell, Morgagni, Vidal and others, the 



TREATMENT. 163 

inflammation extends along the ureters and involves the kidneys. 
In Morgagni's case, the patient died, and an abscess was found in 
one of the kidneys on post-mortem examination. 

Acute cystitis most frequently terminates in resolution, though 
sometimes, • in the chronic form of the disease, in abscess situated in 
the substance of the vesical walls, or between the bladder and rec- 
tum; in hypertrophy, ulceration, rupture, or even gangrene. If 
rupture take place, the escape of the urine into the pelvic cellular 
tissue or peritoneal cavity, soon leads to a fatal termination. 

Treatment. — The treatment of acute cystitis consists in the 
application of cups or leeches to the perineum and hypogastric 
region, prolonged immersion in warm hip-baths, hot fomentations 
and poultices to the hypogastrium, warm opiated enemata, and the* 
internal administration of mucilaginous drinks in small quantities, 
with the addition of the nitrate or bicarbonate of potassa and hen- 
bane. In the rare cases in which retention takes place, catheteriza- 
tion is required, but should not be performed with unnecessary 
frequency, for fear of increasing the inflammation ; and a permanent 
instrument is objectionable for the same reason. At the same time, 
the urine is rendered acrid and irritating by the admixture of mucus 
and pus, and should not be left to accumulate in large quantities. 

In the chronic form of the disease, and in those cases which are 
subacute from the first, we may resort to counter-irritation over the 
hypogastric region by means of croton oil or tartar emetic oint- 
ment. The use of cantharides should be avoided on account of its 
tendency to provoke inflammation of the bladder, unless a stimu- 
lant effect upon the mucous membrane of this viscus be desired. 
Internally, copaiba, turpentine and especially ergot, which I have 
used with very satisfactory results either alone or combined with 
iron, are to be recommended. 

R. Vini ergotae t ^iij. 

Tr. ferri chloridi, ^j. 
M. 
Dose. — A teaspoonful every six hours. 

Dr. Thompson says that the decoction of senega exercises a greater 
influence over the secretion of the bladder in cystitis than any other 
remedy. The same surgeon also recommends an infusion of trit- 
icum repens (3j ad aq. bull. Oj). I have had no personal experience 
with either of these agents. 



164 INFLAMMATION OF THE BLADDEE. 

In decidedly chronic cases of cystitis, injecting the bladder by 
means of a double catheter, first with tepid, then with cold water, 
and finally with some astringent solution, is of great value. I com- 
monly employ either nitrate of silver (gr. j-v ad aquse gj), alum, 
or Squibb's solution of persulphate of iron (sss. ad aquas Oj), and 
repeat the application according to the effect produced, from once a 
day to once or twice a week. 



GONORRHOEA IN WOMEN. 165 



CHAPTER IX. 

GONORRHCEA IN WOMEN. 

The mucous membrane of the genital organs is far more exten- 
sive in the female than in the male. Besides lining the urinary 
canal and the vulva — parts corresponding to the urethra and balano- 
preputial fold in man — it is continued ove^" the' walls of the vagina, 
where its surface is increased by numerous folds, and, reflected over 
the os tineas, extends into the cavities of the cervix and body of the 
uterus. Any portion of this extensive surface may be attacked by 
catarrhal inflammation, which, according to its seat, is called gonor- 
rhoea of the vulva, urethra, vagina, or uterus. Some of these parts 
are more frequently affected than others. Thus, gonorrhoea of the 
vagina is more common than that of the urethra or vulva, and gonor- 
rhoea of the uterus is the least frequent of all. It is rare for all the 
different portions of the female genital organs to be attacked together, 
though two or more are, in many instances, combined as the seat of 
gonorrhoeal inflammation. The manner of union appears to be 
chiefly determined by the anatomical relation of the parts. Thus, 
when the vulva is affected, the urethra and lower portion of the 
vagina are likely to be involved ; while, on the other hand, the upper 
part of the vagina and uterus are not unfrequently implicated 
together. 

Causes. — Gonorrhoea is a much less common disease in women 
than in men. This may be accounted for by several reasons. The 
mucous membrane of the vagina is less sensitive than that of the 
male urethra ; it receives no little protection from the sebaceous and 
mucous secretions which constantly cover it ; the size of the passage 
is such that it can be readily cleansed ; and the urethra, in ^unse- 
quence of its being but very slightly concerned in the sexual act, 
and of the situation of its meatus, is less exposed to contagion. But 
another reason, and one perhaps of still greater weight, is to be found 
in the absence in men of those chronic discharges, the presence of 
which in women is so fruitful a cause of urethritis in the opposite 



\66 GONORRHOEA IN WOMEN. 

sex. When speaking of the causes of gonorrhoea in the male, I 
endeavored to show that it is frequently due to the irritation pro- 
duced by a leucorrhceal discharge; by the menstrual flow, or by the 
normal secretions of the female genital organs. Women, in sexual 
intercourse, are not exposed to these exciting causes of gonorrhoea. 
In a condition of health, there is no secretion about the male genital 
organs capable of exciting inflammation in the female ; while during 
the acute stage of gonorrhoea the pain excited by turgescence of the 
penis is generally sufficient to deter from coitus, and even in cases 
of gleet, the amount of the discharge is so small, the urethra so 
frequently cleansed by the passage of urine, and the vagina so well 
protected by sebaceous matter, that intercourse may often take place 
without much exposure to the woman. Owing to these circumstances, 
Women more frequently communicate than receive gonorrhoea. 

It would seem to be a fair deduction from the foregoing, that, 
taking a given number of gonorrhoeal cases in the two sexes, more 
are due to infection in women than in men ; and such I think is 
unquestionably the fact. But while assigning to direct contagion 
the first place in the etiology of the gonorrhoea of women, other in- 
fluences must not be overlooked. These, however, are less appreci- 
able in the female than in the male. The history of women seeking 
advice for gonorrhoea can rarely be ascertained with certainty, or 
their disease traced with accuracy to its source. It is notorious that 
a woman often receives the embraces of several men within a short 
space of time, and there are many reasons for her concealing import- 
ant facts which a man would readily confide to his physician. It is, 
therefore, only under peculiar circumstances that we can satisfac- 
torily ascertain the origin of gonorrhoea in women ; still, opportuni- 
ties for such investigation do sometimes occur, and, in several which 
I have met with, it was evident that the disease was due to other 
causes than contagion. Thus, I have known intercourse with a 
healthy man to excite acute and extensive inflammation of the geni- 
tal organs in women suffering from leucorrhcea. and congestion of 
the cervix, especially if the stimulus of liquor was added to that of 
coitus. In such cases, chronic may readily be transformed into acute 
inflammation, in the same way as a gleet in man may be changed 
into a clap. In some instances, I have had reason to believe that 
the frequent repetition of the sexual act has produced gonorrhoea in 
women free from any previous disease, and it is a well established 
fact that a purulent discharge sometimes follows the first exercise of 
marital rights, although there may have been no laceration of the 
female genital organs. In general, the causes of gonorrhoea in wo- 



CAUSES. 161 

men, independently of contagion, may be enumerated as follows: 
Immoderate sexual intercourse, violence, masturbation, the presence 
of vegetations, syphilitic or other eruptions, errors of diet, ascarides 
in the rectum, and the external influences of cold, moisture, etc. 

Many women have, during pregnancy, a muco-purulent discharge, 
which usually makes its appearance after the fourth or fifth month, 
though sometimes before, and chiefly affects the upper portion of the 
vagina. An examination of the vaginal mucous membrane reveals 
the existence of numerous granulations, similar to those observed 
also in some cases of vaginitis from contagion. Cazeaux states that 
this discharge may produce disorder of the digestive functions, as 
shown by the coexistence of gastralgia, which is more or less severe 
according to the intensity of the vaginitis. 1 The discharge usually 
disappears spontaneously after the termination of gestation. 

Vaginitis may be attendant upon scarlet fever, or it may follow 
this and the other exanthemata as a sequela. 2 

Very young girls may be attacked with inflammation of the genital 
organs, producing a copious purulent discharge from the vulva, and 
sometimes from the vagina also, the cause of which has often been 
misapprehended. It has been supposed that the disease was con- 
tracted from men who had been seen to caress or fondle them, and 
innocent persons have been arrested and tried on this charge. No 
one in such cases has done more for the honor of our profession 
and for the cause of humanity than Mr. Wilde, of Dublin, who has 
repeatedly come forward when the accused party was about to be 
convicted for an offence which he never committed, has shown the 
groundlessness of the charge and proved his innocence. In most 
cases, the discharges in question are no more venereal in their nature 
than the otorrhcea which is so common in children. Their predis- 
posing cause is general cachexia, or, as it is commonly called, a 
strumous diathesis. The exciting cause may be deficient cleanliness, 
derangement of the digestive functions, the irritation of teething, 
and the presence of ascarides in the rectum, or within the vulva, 
where they may have found their way from the gut. Such discharges 
are contagious when applied to the ocular conjunctiva, and not less 
so, in all probability, if brought in contact with the genital organs 
of a second person ; thereby proving that the contagiousness of gon- 
orrhoeal matter depends upon the seat of the disease, and not upon 

1 Traits de l'Art des Accouchements, 4e Edition, p. 317. 

2 Cormack, London Jojirnal of Medicine, Sept., 1850, p. 872; and Barnes, Medi- 
cal Gazette, July 12, 1850, p. 65. 



168 GOXOERHCEA IN WOMEN. 

the presence of a specific poison necessarily transmitted from one 
individual to another. 

Symptoms. — The initiatory symptoms of gonorrhoea in women 
are often obscured, in the rare instances afforded for their examina- 
tion, by the previous existence of a leucorrhceal discharge. They 
do not differ from the early symptoms of inflammation of other 
mucous membranes, and consist in the gradual development of 
swelling, redness and tenderness, and an increase of, and change in, 
the secretion of the part. The discharge varies in consistency and 
color as in gonorrhoea in the male. It is at first transparent and 
mucous, then muco-purulent, and finally, when the disease has 
attained its height, thoroughly purulent. When secreted by the 
vagina it is acid, fluent, creamy, and readily removed from the sur- 
face ; when derived from the cavity of the cervix, 1 without being 
mixed with the acid matter of the vagina, it is alkaline, nearly 
transparent, tenacious like the white of egg, and very adhesive. 
Examined under the microscope, the vaginal secretion is found to 
consist of pus-corpuscles, mucus, an abundance of epithelial scales 
and flakes of epithelium in masses ; while the viscid plug drawn 
from the cervix, which, as shown by Dr. Tyler Smith, is glandular 
in its structure, exhibits mucus-corpuscles, oil-globules and purulent 
matter. The consistency and yellowish color of the vaginal secretion 
are dependent upon the quantity of organized elements it contains. 
The thicker it is, the more opaque, and* the more resemblance it bears 
to cream or pus, the greater the quantity of pavement epithelium 
and pus-globules, as shown by the microscope. 2 

M. Donne has also called attention to the presence of a small 
infusorial animalcule which he at first supposed to be pathognomonic 
of gonorrhoeal vaginitis. He has since renounced this opinion, but 
still asserts that the Trichomonas is not seen in healthy vaginal 
mucus, but only when there is a large admixture of pus-globules. 
Farther researches by Kolliker and Scanzoni 3 would show that it is 
never present in the secretion of the cervix, so that it cannot be a 
mere cell of ciliary epithelium, and these authors state that there 
can be no doubt of its independent animal nature. It was first 

1 The most convenient method of collecting the cervical secretion for the purpose 
of examination, unmixed with the vaginal mucus, is by means of Lallemand's porte 
oaustique, uncharged. 

2 Pathology and Treatment of Leucorrhoea, Phil, ed., 1855, p. 122. 

8 Das Seerct d. Schleimhaut d. Vagina und des Cervix Uteri. Scanzoni's Beitrage, 
Bd. ii.. p. 126. VVurzburg, 1855. 



GONORRH(EA OF THE VULVA. 169 

found by them in pregnant women, and, after their attention was 
called to it, in more than half the women whom they examined. 
Hence it cannot be considered as characteristic of gonorrhoea. Still, 
it is never met with in perfectly healthy mucus, destitute of pus- 
globules. It appears to depend upon certain changes in the vaginal 
secretion, and is not developed to any extent except in mucus which 
is clearly abnormal. 1 

Traces of a discharge from the genital organs are to be sought 
for chiefly upon the posterior portion of a woman's linen, and not 
upon the anterior. The absence of any external evidence of disease 
does not, however, prove her sound ; since the upper portion of the 
vagina may be inflamed and the secretion be retained within the 
vulva. The symptoms of gonorrhoea in women vary according to 
the part affected, and it is convenient to make a corresponding divi- 
sion in their description, recollecting, * at the same time, that the 
different forms may be more or less combined in a given case. 

Gonorrhoea of the vulva is less common than that of the vagina, 
and, in many cases, is secondary to the latter, being produced by 
contact with the discharge flowing from above. It is, however, 
often, primary, and is that form which is commonly met with as the 
result of violence, or the presence of vegetations and syphilitic or 
other eruptions, as venereal ulcers, mucous patches, etc. The gon- 
orrhoea of young girls, already referred to, is also, in most cases, 
vulvar. 

The patient's attention is early attracted to the part by a sensation 
of heat and pruritus. • On examination, the mucous membrane is 
found to be reddened, tumefied, and more moist than natural. As 
the disease advances the discharge increases in quantity and be- 
comes muco-purulent, or purulent, and very offensive. The labia 
and nymphse are swollen to such a degree that it is almost impossi- 
ble to expose the orifice of the vagina. If the nymphse be naturally 
large, they may swell to such an extent as to protrude beyond the 
labia and become constricted ; a condition which may be compared 
to paraphymosis. The mucous membrane may be deprived of its 
epithelium in patches, identical in character with the superficial 
excoriations of balanitis. The inflamed parts are exceedingly sen- 
sitive to the slightest touch or pressure, and motion is very painful. 
The last drops of urine fall upon the excoriated surface and give 
rise to severe scalding. The discharge collects in the hair on the 
mons veneris and upon the external surface of the labia, and flows 

' Traite Pratique des Maladies des Organes Sexuels de la Femme, par F. W. de 
Scanzoni ; traduit de l'Allemand, Paris, 1858, p. 452. 



170 GONORRH(EA IN WOMEN". 

upon the integument of the perineum, and upon the upper portions 
of the thighs. Wherever it remains for any length of time it irri- 
tates and inflames the skin, which soon assumes an erythematous or 
even excoriated condition, and itself secretes an acrid humor. If 
the discharge comes in contact with the anus, as is very likely to 
occur when the patient lies upon the back, it may produce irritation 
of the rectum, attended with frequent desire to go to stool, pain on 
the passage of the feces, and sometimes slight diarrhoea. 1 

The sexual desires are often heightened, and amount at times to 
nymphomania, but coitus is attended with severe pain, if it even be 
possible. No other form of gonorrhoea in women equals this in the 
suffering which it occasions. This is partly owing to circumstances 
already mentioned, and partly also to the great sensibility possessed 
by the vulva in common with other outlets of mucous canals. The 
general system sometimes sympathizes with the local disease, and 
the patient is found to be hot and feverish. All cases of vulvar 
gonorrhoea are not, however, so severe as that just described. In- 
stances occur in which there is but little redness, tumefaction, or 
sensibility, and merely an increase of the secretion of the part ; and 
the symptoms may vary all the way from this mild character to the 
intensity of the above description. 

The anatomy and pathology of the glandular apparatus of the 
female genital organs have been admirably given by M. Huguier, 2 
and no account of vulvitis would be complete without including a 
description of the changes which take place in these bodies. The 
vulva is abundantly supplied with sebaceous and muciparous folli- 
cles, which are lined by a prolongation of the mucous membrane. 
Travelling along this continuous surface the inflammation readily 
gains access to the interior .of the follicles, which soon pour out a 
thick purulent secretion from their mouths. 

The entrance to the vagina is also provided with two larger and 
more deeply situated secretory organs, which, although noticed by 
several anatomists subsequent to the seventeenth century, were 
comparatively unknown up to quite a recent date. These glands 
were first discovered by Duverney in the cow, and afterwards by 
Bartholin in woman, but, having been sought for in vain by Haller, 
they were entirely forgotten, until attention was again called to 
them, in 1840, by Tiedmann, 3 of Heidelberg, and by M. Huguier, of 
Paris, in 1850. They are now known by the name of Duverney's, 

1 Battmes, Precis sur les Maladies Ve'ne'riennes, t. ii., p. 163. 

8 Memoires de l'Acad^mie de M6d., 1850, p. 529. 

9 Von den Duverneyschen Driisen ; Heidelberg, 1840. 



GONORRHCEA OF THE VULVA. 171 

Bartholin's, Cowper's, or the vulvo-vaginal glands. They -are situ- 
ated, one on either side of the entrance to the vagina, in the trian- 
gular space, bounded by the ascending ramus of the ischium, the 
vaginal orifice, and the transversalis perinaei muscle, and are covered 
by the superficial perineal fascia, and some fibres of the constrictor 
vaginae. Their size varies in different subjects, and they appear to 
be largest in women addicted to sexual intercourse. When most 
developed their diameter usually measures about six-tenths of an 
inch. They are conglomerate glands, consisting of congeries of 
small tubes, surrounded by a common envelope, and during the act 
of coitus, pour out a copious secretion of albuminous fluid, by 
means of a duct six or seven lines in length, opening just in front 
of the hymen, or near the lateral and posterior carunculae myrti- 
formes, which often conceal the orifice. 

The inflammatory process may invade this duct and the gland 
beyond it, in the same manner that it does the superficial follicles ; 
and when suppuration has taken place, if the matter do not find 
free exit through the natural outlet of the gland, an abscess is 
formed either within the dilated duct, or in the substance of the 
gland itself; the former being generally the case when gonorrhoea 
is the exciting cause. 

Now, abscesses in the neighborhood of the vulva are quite com- 
mon in cases of vulvitis, and though some of them are situated in 
the submucous cellular tissue, yet most of them are of the character 
above described, and are seated in the vulvo-vaginal gland or duct. 
A frequent and peculiar feature which marks them, is the facility 
with which, having once emptied themselves, they again fill up on 
the occurrence of any slight cause, as a return of the menstrual 
period, indulgence in sexual intercourse, exacerbation of the vulvar 
inflammation, etc. This circumstance has led some authors to the 
erroneous conclusion that these abscesses are surrounded by a true 
cystic wall, whereas their envelope continues to be, as at first, either 
the dilated duct or gland, which, to a certain extent, performs the 
office of a cyst. These glandular abscesses, however, may generally 
be recognized without much difficulty. The patient complains of 
a "swelling" in the vicinity of the vulva, which, on examination, is 
found to occupy the lower third of the labium, and border upon 
the posterior commissure. The affected side is more prominent 
than its opposite, and the labium is pear-shaped, with its broader 
extremity directed backwards and inwards towards the median 
line; the integument on its external aspect preserves its normal 
color, and is free and movable, while the internal surface of mucous 



172 GONORRHOEA IX WOMEN. 

membrane is red and adherent to the tumor. The part is exceed- 
ingly sensitive to the touch, and the patient can neither walk, stand, 
nor sit, without difficulty, owing to the pain excited by the slightest 
pressure. The contents of the tumor are occasionally discharged 
through the normal duct of the gland, but usually, unless art inter- 
vene, the abscess bursts in the neighborhood of the glandular orifice, 
and very rarely on the external or integumental surface of the 
labium. M. Huguier contradicts the statement made by Vidal and 
other authors, that a . recto-vaginal fistula is liable to form. This 
never occurs, according to the first named surgeon, if the rectum 
be in a sound condition. The frequent recurrence of abscesses of 
the vulvo-vaginal gland, or duct, is a source of great annoyance to 
women of the town, when suffering from chronic inflammation of 
the vulva. 

Dr. Salmon 1 has called attention to certain cases of gonorrhoea, 
in which the vulvo-vaginal gland and duct are alone affected ; the 
remainder of the genito-urinary organs retaining their normal con- 
dition. According to this surgeon, the affection is quite common, 
and especially so among young prostitutes, in whom it would seem 
to be due to the irritation of coitus upon parts as yet tender. The 
patient experiences no pain or inconvenience, and an examination, 
such as is ordinarily made, might lead to the conclusion that the 
genital organs were sound; but if the labium, on one or both. sides, 
be firmly pressed against the ramus of the ischium, the gland, which 
is not perceptible to the touch in a state of health, may be felt as a 
moderately firm tumor, and its muco-puriform contents are seen to 
escape from the orifice of the duct. Dr. Salmon is of the opinion 
that vulvo-vaginal gonorrhoea will explain many cases in which a 
clap is contracted from a woman apparently healthy. Farther 
researches, however, are requisite to establish beyond a doubt the 
statement, that it is a common occurrence for gonorrhoea to affect 
primarily and exclusively the parts in question ; although, after the 
subsidence of an attack of vaginitis or vulvitis, the inflammation 
may undoubtedly lurk for an indefinite period in the vulvo-vaginal 
gland and duct. 

Vaginitis is more common than any other form of gonorrhoea in 
women. The whole extent, or only a portion of this passage may be 
inflamed. The lower part is more or less implicated in most cases 
of vulvitis, while frequently the upper part is alone involved, and 
the woman might be supposed free from disease, if not examined 

1 Mftu. Times and Gaz., Dec. 23, 1854, p. 646, quoted from L' Union MeMicale.— • 
Braithwaite's Retrospect, Part 31, p. 208. 



VAGINITIS. 173 

with the speculum ; especially as, from the comparative insensibility 
of the upper portion of the vagina, her sensations are an unreliable 
index of its condition. Eicord states that the posterior wall of the 
vagina is more frequently affected in leucorrhcea, and the anterior 
wall in gonorrhoea. 

The modern application of the speculum to the study of venereal 
diseases (for which we are indebted to Eicord) has rendered an affec- 
tion, which was before obscure and of difficult diagnosis, at once 
clear and easily recognizable ; and the zeal, of late years, brought 
to the pathological investigation of the female genital organs, has 
induced many observers to describe the lesions of vaginitis with 
great minuteness and detail. It is not to be regretted that these 
lesions have been subjected to so severe a scrutiny, although they 
have for this reason acquired an unmerited degree of importance, 
since it has been shown that they are characterized by no features 
sufficiently peculiar to indicate their venereal origin, and that they 
are, in nearly all respects, identical with the more familiar morbid 
appearances of other mucous membranes, as the conjunctiva oculi, 
the lining membrane of the mouth, ear, etc. 

The speculum should not be employed during the acute stage of 
vaginitis, as it is likely to excite severe pain and irritate the in- 
flamed tissues. The presence of the catamenia is also a contraindi- 
cation to its use. The ordinary cylindrical instrument, made of 
glass and coated with a layer of India rubber, is of easy introduction, 
and is generally sufficient for the examination of the vagina in sus- 
pected cases of gonorrhoea, but when it is desired to make local appli- 
cations, or when thorough exposure of all the recesses of this pass- 
age is requisite in order to discover if any concealed chancre, or 
chancroid, be present, a valvular speculum should be preferred. In 
order to remove the discharge which may obstruct the field of vision, 
the surgeon should provide himself with several swabs, which may 
be conveniently made by winding cotton wadding around the end of 
a thin splinter of wood. The patient may lie in the " obstetric posi- 
tion" upon her left side, or, as I prefer, upon her back, with the 
knees drawn up ; and delicacy requires, even when treating a woman 
of the town, that she should be covered with a sheet. 

When the vaginitis is intense and seen at an early period, a por- 
tion or the whole of the vaginal walls may be found red, hot, and 
dry, and entirely destitute of moisture. Eicord states that in several 
instances he has seen this condition finally terminate in resolution 
without the slightest discharge appearing at any time. Similar cases 
of dry or erysipelatous gonorrhoea have been reported as occurring 



174. GONORRHOEA IN WOMEN. 

in men, although the impossibility of examining the internal surface 
of the urethra throughout its whole extent has left them open to 
criticism. Generally, however, this dry condition of the vagina, if 
present at the outset, is succeeded in the course of twenty-four hours 
by the appearance of a discharge, which, at first transparent, after- 
wards undergoes changes similar to those which occur in gonorrhoea 
in the male ; and when the disease has attained its height, the vaginal 
walls are bathed with offensive purulent matter of a creamy or green- 
ish color, or sometimes streaked with blood. Before proceeding 
with the examination, the field of the speculum must be cleared from 
the discharge by the assistance of the swabs of cotton-wadding, 
when the mucous membrane will be exposed. This surface is found 
to be red and tumefied. The redness varies in intensity and also in 
extent. It is sometimes uniform and at others arranged in spots or 
strise. Frequently patches are seen from which the epithelium has 
become detached, forming superficial abrasions similar to those met 
with in balanitis, or resembling blistered surfaces. Another condi- 
tion which is at times met with has received the name of granular 
vaginitis. It consists in a development of the vaginal papillae, which 
project above the surrounding surface, and are readily recognized 
by their darker red color. These granulations are most frequently 
observed in the upper part of the vagina, where they may exist in 
large numbers covering the whole surface, or they may be merely 
scattered here and there. They have been erroneously regarded by 
Dr. Deville as peculiar to the vaginitis of pregnant women. 1 They 
are analogous to the granulations which are so common upon the 
palpebral conjunctiva. Eicord says that, in one case of vaginal 
gonorrhoea, he observed an eruption presenting every appearance of 
herpes phlyctenodes situated upon the deeper portion of the vagina, 
and Ashwell speaks of " herpetic pustules," which by bursting form 
ulcers. 

In addition to the above symptoms, vaginitis is characterized by 
increased heat and sensibility. The former may be verified by 
introducing a finger within the vagina, when the parts will be felt 
to be much hotter than natural. The degree of sensibility varies, 
and is greatest when the vulva is also involved. In such cases, it 
is generally quite impossible to introduce a speculum owing to the 
pain which it excites ; but when the disease is confined to the vagina 
this instrument may often be employed without causing much suffer- 
ing. During the course of vaginitis, there is often a frequent desire 

1 Archives G6ne"rales de MeM., 4e se"rie, vol. v., p. 305. 



GONORRHOEA OF THE URETHRA. 175 

to pass the urine, and dull pain is felt in the hypogastric region, 
owing to sympathy excited on the part of the bladder. 

Gonorrhoea of the vagina rarely continues any length of time 
without extending to the mucous membrane covering the cervix, 
which may exhibit lesions identical with those now described, but 
more especially patches of superficial abrasions. Gonorrhoea of the 
uterus is commonly confined to the cavity of the cervix. It is some- 
times secondary in this situation, being occasioned by the extension 
of the disease from the vagina, while at other times it is primary, 
and if the patient be examined at a sufficiently early period, the 
parts may be found in a perfectly healthy condition until the uterus 
is exposed, when the lips of the os are seen to be tumefied and 
red, the cervix congested and enlarged, and its cavity filled with 
tenacious and transparent muco-purulent matter. This secretion 
owes its transparency to the alkali which it contains. It becomes 
curdled and opaque when mixed with the vaginal acid, and hence 
cannot always be recognized after it has descended into the vagina 
or is discharged from the vulva. The fact that gonorrhoea confined 
to the cervix uteri may readily be overlooked, may explain some 
of the cases in which a clap is derived from an apparently healthy 
woman. 

The acute stage of vaginitis rarely continues longer than a week 
or ten days, and may be of much shorter duration. As the acute 
symptoms subside, the pain and difficulty of motion are diminished. 
The discharge becomes less copious and purulent, and the redness 
and tumefaction of the tissues gradually disappear. After this 
partial advance towards recovery, however, the disease often lingers 
for an indefinite period, and is extremely difficult to eradicate. The 
vaginal walls may seem to have recovered their normal condition, 
having lost the morbid appearances which characterized the acute 
stage, but there is still a small amount of discharge from their surface 
or from the cervical cavity, which is capable of producing gonor- 
rhoea in the male. 

Gonorrhoea of the urethra usually coexists with that of the vulva, 
or vagina, and sometimes with that of the uterus alone. Cases, how- 
ever, are reported in which this was the only part of the genital 
organs affected. Gibert met with three such instances ; ] Eicord with 
two, 2 and Cullerier with one ; 3 and in several of them, it was noticed 

1 Gibert's first case was published in the Revue M6dicale, t. i., 1834. He has also 
given two other cases in his Manuel sur les Maladies Syphilitiques, p. 284. 

2 Memoires de l'Acaddmie Royale de M6d., t. 2e, p. 159. Paris, 1833. 

3 Dictionnaire de Mecl. et de Chir. prat., t. 4e, p. 253. 



176 GONORRHOEA IN WOMEN. 

that the stains of the discharge upon the woman's linen were sma\l 
and circular, instead of being large and irregular as in cases of 
vulvar and vaginal gonorrhoea. 

The shortness of the urethra in women and the oblique position 
of the canal, which favors the spontaneous flow of matter, render the 
diagnosis of the urethritis less easy than in the male. The discharge 
in cases of vulvitis, also, being seen, as might easily happen, in the 
vicinity of the meatus, may be erroneously supposed to come from 
that orifice. Again, the passage of urine causes all traces of ure- 
thritis to disappear for a time. An examination, in order to be 
conclusive, should be made at least an hour or two after an evacua- 
tion of the bladder, and any discharge around the meatus should 
first be removed. The finger may then be passed into the vagina, 
and pressure be made against the pubic arch, in the course of the 
canal, from behind forwards ; when, if urethritis be present, one or 
more drops of purulent matter will appear at the meatus, the lips 
of which will be found swollen and inflamed ; and the introduction 
of a sound into the canal is attended with considerable pain. Scald- 
ing during micturition may easily be a deceptive symptom, since it 
may be produced to a still greater degree by the contact of the urine 
with the excoriated mucous membrane of the vulva, when the latter 
is involved. If no vulvitis be present, it is a symptom of value. 
Gonorrhoea of the urethra, occurring in women otherwise healthy, 
does not show the same tendency to run into a gleet as in men. It 
almost always disappears before the accompanying vaginitis or vul- 
vitis, and is therefore to be regarded as of secondary importance. 1 
In broken-down constitutions, however, and in women who have 
borne many children, or who are suffering from congestion of the 
abdominal viscera, it may assume a chronic form, and prove exceed- 
ingly obstinate. A thickening takes place throughout the whole 
canal, which can be traced as a firm cord behind the pubis, and may 
be seen standing out in relief at the upper part of the entrance of 
the vulva, when the nymphae are separated. This condition is 
attended with uncomfortable sensations in the part, and a frequent 
desire to pass water, aggravated by motion, by coitus and the return 
of the menstrual period, and relieved by rest and the recumbent 
posture. 2 

The value of urethritis as indicating contagion has been noticed 

i Dubano Fardkl, Mdmoire sur la Blennorrhagie chez la Femme, et ses Diverses 
Complications. Journal des Connaissances Medico-Chirurg., Juillet, Aout, et Sep- 
lemore, 1840. 

2 West, Lectures on the Diseases of Women, 2d ed. p. 613. 



COMPLICATIONS. 177 

"by many authors. In the majority of cases in which it is present, 
patients acknowledge that they have been exposed to impure inter- 
course. On the other hand, urethritis is absent in many cases in 
which the disease undoubtedly originated in contagion, and the fact 
is well established that it may depend upon uterine displacements 
and other causes independent of coitus ; hence it cannot be said 
to furnish more than presumptive proof that a woman has been 
unchaste. 

Complications. — Bubo is a less frequent complication of gonor- 
rhoea in women than in men, and Eicord states that it very rarely 
occurs unless the urethra is affected. 1 Durand Fardel reports the 
case of a woman who had a rape committed upon her by several 
men, and in whom a bubo formed and terminated in suppuration. 2 
An examination showed that she had acute inflammation of the 
vulva and vagina, and that there was no laceration or ulceration of 
the mucous membrane, yet the violent origin of the disease would 
excite suspicion as to the bubo being due entirely to the gonorrhoea. 
No mention is made of the condition of the urethra. 

Vegetations, mucous patches or tubercles, chancroids and chancres, 
are frequently found to coexist with gonorrhoea of different portions 
of the female genital organs, and especially with vulvitis. Their 
presence is a constant source of irritation, and their removal is 
essential to a cure of the primary disease. Vegetations should be 
destroyed by the knife or caustics ; mucous patches are a symptom 
of syphilis, and require general as well as local treatment; and 
chancres and chancroids are to be treated according to rules to be 
laid down hereafter. 

As a general rule, gonorrhoea in women is confined to the external 
organs of generation, or does not extend above the cavity of the 
cervix, but cases are sometimes met with in which the internal sur- 
face of the body of the uterus is involved, or in which there is true 
metritis. In exceptional instances, also, the inflammation may 
extend to the Fallopian tubes, and even through the continuity of 
tissue, to the peritoneum. At the post-mortem examination of a 
case of this character, M. Mercier 3 found one of the Fallopian tubes 
obliterated by a deposit of lymph upon its fimbriated extremity, 
and the peritoneal surface inflamed to a considerable extent around 
it. West mentions two successive attacks of vaginitis, at an interval 

1 Notes to Hunter, 2d ed. p. 106. 2 Op> oit%. 

3 Memoire sur la Peritonite considered comme Cause de Sterilite chez les, lf<munes>; 
Gaz. Me"d., 1838, p. 577; also Gaz. des Hop., 1846, p. 432. 

12 



178 GONORRHOEA IN WOMEN. 

of eighteen months in the same patient, which were followed by 
such severe peritonitis as to call on each occasion for the abstraction 
of blood. 1 

Inflammation of the ovaries as a complication has also been seen 
by several authors, and has been compared to the swelled testicle 
which occurs in the male. The symptoms are well described in a 
case related by Kicord. The patient, aged thirty-two, an inmate of 
the Hopital du Midi, was suffering from acute gonorrhoea of the 
uterus and external genital organs, when a swelling suddenly 
appeared in the left iliac fossa. The part was very sensitive to the 
touch and its temperature increased. There was considerable febrile 
excitement and nausea. The patient lay on her back, inclined 'a 
little to the left, with the thighs flexed. The discharge from the 
urethra and vagina had almost entirely disappeared. Pressure 
upon the neck of the uterus, with the finger introduced within the 
vagina, was not painful ; but when the womb was pressed toward 
the right side, pain and a sense of tension were felt in the left broad 
ligament. Pressure toward the left side, tried for the sake of com- 
parison, caused scarcely any inconvenience. The passage of the 
feces and urine, and all motion of the abdominal walls were painful. 
Under the use of antiphlogistic remedies, these symptoms gradually 
diminished and disappeared in about twelve days, and at the same 
time the discharge increased in quantity. The patient, however, 
was shortly afterwards seized with a second attack on the opposite 
side, with the same symptoms and the same suspension of the 
discharge. 2 

My friend Dr. Geo. T. Elliot, Jr., of this city, informs me that he has 
met with two cases of pelvic cellulitis, originating in gonorrhoea. 
So far as I am aware, this dangerous affection has never before been 
noticed as a complication of gonorrhoea in women. The statement 
of so accurate an observer as Dr. Elliot is entitled to great weight, 
but it is to be regretted that notes of the cases, essential to render 
them conclusive as evidence of the fact stated, were not taken. 

Diagnosis. — Before the application of the speculum to the study 
of venereal diseases, the diagnosis of gonorrhoea in women was often 
difficult and sometimes impossible ; and the discharges of vaginitis 
and of various syphilitic lesions within the vulva were confounded 
together. To a surgeon of the present day, acquainted with modern 

I Op. cit., p. 627. 

» Notes to Hunter, p. 107. 



TREATMENT. 179 

methods of investigation, such mistakes are not likely to occur. 
With the recognition of the disease, however, our power, so far as 
diagnosis is concerned, ceases. It is impossible to go farther and 
determine its origin. Many authors have attempted to give diag- 
nostic signs as between gonorrhoea originating in contagion and that 
•produced by other causes, but they have all most signally failed to 
produce any which are at all satisfactory, simply for the reason that 
none such exist. " The microscope fails to furnish us with a means 
of distinguishing between gonorrhceal and simple vaginitis, and no 
symptom or combination of symptoms is absolutely conclusive on 
this point." 1 Acute inflammation and the presence of urethritis may 
render impure intercourse probable, but cannot be regarded as deci- 
sive ; and what is wanting in the physical diagnosis must be sought 
for in the history of the case. 

Treatment. — The treatment of the different forms of gonorrhoea 
in women varies but little in the acute stage of the disease. It is 
chiefly during the chronic stage that any variation is required to 
meet special indications, presented by inflammation of particular 
portions of the mucous membrane. Moreover, nature does not 
always, nor indeed in most instances, follow the classification which 
we have found it convenient to adopt ; several of the genito-urinary 
organs are generally involved together — more commonly the vagina 
and vulva — and the treatment of this most numerous class of cases 
will first claim our attention. 

The chief remedies adapted to the acute stage are rest, cathartics, 
hot baths, lotions, and a general antiphlogistic regimen. It is of the 
first importance that the patient should abstain from exercise of all 
kinds, and, if possible, be confined to her bed ; indeed, in most cases 
her own sensations demand this, without the order of the surgeon. 
Meats and stimulants should be forbidden, and the diet restricted to 
weak tea, toast, a decoction of flaxseed, rice or barley-water, gruel, 
etc., unless the symptoms are subacute from the first, or the patient 
debilitated. In selecting a cathartic at the outset of the disease, 
preference should be given to a mercurial, for the purpose of un- 
loading the abdominal and pelvic vessels, and the bowels should 
afterwards be freely opened every day, by small doses of Epsom 
salts, citrate of magnesia and other salines. Aloes, and the numerous 
preparations which contain it, should be avoided, on account of its 
tendency to produce congestion of the haemorrhoidal vessels. 

Leeches— -The local abstraction of blood is not generally necessary 

1 West, op. cit., p. 628. 



180 GONORRHOEA IN WOMEN. 

except in decidedly acute cases, when from six to ten leeches may 
be applied in the neighborhood of the vulva. There - is one serious 
objection to their use, however. We can never be certain — except 
after an examination with a speculum, which the sensibility of the 
parts in this stage does not permit — that there is not a chancroid 
concealed within the vulva, the secretion of which may inoculate the 
leech-bites, and give rise to troublesome sores. Hence if leeches be 
employed, they should be applied to the upper part of the groins or 
hypogastric region, where the discharge is not likely to reach, and 
their bites should be protected by an application of collodion or by 
cauterization with nitrate of silver. 1 

Baths and Lotions. — A hot bath, repeated once or twice a day 
during the acute stage, is very grateful to the feelings of the patient, 
and beneficial in equalizing the circulation and relieving the local 
inflammation ; and immersion of the whole body is to be preferred 
to hip-baths. 

Meanwhile, the external genital organs should be frequently bathed 
with some emollient lotion, and a piece of lint soaked in the same 
be inserted between the labia, in order to separate the inflamed sur- 
faces and absorb the discharge. The following is an excellent for- 
mula for this purpose : — 

R. Decocti papaveris 3 pts. 

Liquoris plumbi subacetat. dilut. 1 pt. 
M. 

Sedatives, of which Dover's, or Tully's powder is perhaps the best, 
should be administered at night to induce sleep, and also at intervals 
during the day, if the pain is severe, or the patient nervous and 
irritable. 

The above measures are the only ones admissible during the acute 
stage of the disease, especially if the vulva is involved ; in which 
case the insertion of an enema tube is too painful to admit of injec- 
tions. When, however, the inflammation is chiefly confined to the 
vagina, the lotion just mentioned may be injected into this canal 
every few hours, and in many cases of a subacute type, injections 
may be used from the very commencement. As soon as the sensi- 
bility of the parts will permit, it is also desirable to introduce a 
speculum, and ascertain if any ulcer be present. 

The kind of syringe used, and the mode of injecting, are matters 
of no little importance. The small metallic or glass instruments in 
common use are entirely inadequate for the removal of the discharge. 
The astringent ingredients of the first portion of fluid injected are 

1 Ricord, Le9ons Cliniques, Gaz. des Hopitaux, 1846, p. 157. 



TREATMENT. 181 

spent in coagulating the purulent matter collected in the vagina. 
To wash away the coagula thus formed, and exert a medicinal effect 
upon the mucous membrane, the quantity of the injection should 
not be less than a pint. A pump syringe, or better still, one of 
Davidson's or Mattson's syringes, made of India rubber and pro- 
vided with metallic valves, will enable the patient to inject any 
desired quantity with one introduction of the tube. While using 
the injection, the patient should lie on her back, with the pelvis 
elevated ; if she merely stoop down, the fluid escapes as fast as it is 
injected, and fails to reach the deeper portions of the canal. By 
means of a bed-pan the wetting of the floor and clothes may be 
avoided. 

As a general rule, injections of greater strength may be used for 
women than for men, and for the sake of cheapness and convenience, 
they are commonly made more simple in their composition. The 
patient may be supplied with the solid ingredients, and allowed to 
mix them as required, and in order to avoid the expense of having 
them put up by the druggist in divided portions ready for use, it is 
desirable, among the poor, to supply them in bulk. A little instruc- 
tion from the surgeon will enable the patient to measure them out 
with sufficient accuracy. A heaping teaspoonful, or, in other words, 
as much as can possibly be taken up by a teaspoon, of the more 
common ingredients of injections, is nearly as follows : — 

Alum gij. 

Sulphate of zinc ^ij. 
Acetate of zinc ^iss. 
Subacetate of lead giij. 
Tannin ^ss. 

From one to two drachms of either of these salts to the pint of 
water, is the average strength employed, but the ratio should always 
be proportioned to the effect produced, and the sensibility of the 
parts. Whenever severe or long- continued pain is induced, the 
strength of the solution should be at once diminished, and after- 
wards increased, as the tenderness becomes less. I would repeat 
what I have said with reference to injections for men, that young 
practitioners often lose time, to the neglect of more important mat- 
ters, in frequently changing from one form to another ; cases, how- 
ever, occur, in which one injection appears to lose its effect, and 
another may be substituted with advantage, but no change should 
be made, unless it is evident that the unsatisfactory result is not due 
to a faulty method of using the syringe, or to constitutional causes, 



182 GOXOKKHCEA IN WOMEN". 

or again, unless the solution, however diluted, excites severe pain 
and uneasiness. 

When the subsidence of the more acute symptoms first permits 
the introduction of an enema tube, a drachm of alum may be dis- 
solved in a pint of flaxseed tea, and injected warm, but the temper- 
ature should be gradually lowered, and the injection ultimately 
used cold. Injections of cold water alone, during the chronic stage 
of vaginitis, are of great value. They not only cleanse the parts, 
but exert a tonic influence upon the vagina and neighboring organs. 
Their effect, however, is increased by the addition of alum, or 4he 
other salts above mentioned. They should be employed from two 
to three times a day, but must be omitted, for'obvious reasons, during 
the menstrual periods. 

A combination of tannin and alum, as recommended by Dr. 
Tyler Smith, 1 is also an excellent form of injection, and one which 
I have prescribed with much success. The proportions are 3ss-j of 
tannin, and 3ij of alum to the pint of water. Tannate of alumina 
is formed by chemical decomposition. It should be recollected, 
however, that tannin, and the salts which contain it, stain the linen 
almost as indelibly as nitrate of silver, which is a serious objection 
with many women to its use. I have also employed injections of 
the sulphate and acetate of zinc, and subacetate of lead, with satis- 
factory results. Labarraque's solution of chlorinated soda, diluted 
with from eight to twelve parts of water, may be injected, when the 
discharge is very offensive. A solution of chloride of zinc, of the 
strength of from one to three grains to the ounce of water, is a 
favorite injection with some surgeons. 

The following formula, intended as a substitute for the aromatic 
wine of the French Pharmacopoeia, is one of the best injections for 
general use : — 

R. Claret wine, 

Compound spirits of lavender, aa ^ v. 

Tincture of opium ^ss. 

Water ^iijss. 

Tannin 3J— |j. 
M. 

I usually direct the patient to add two tablespoonfuls of this 
mixture to a tumblerful of water, and to gradually increase the 
strength. 

I rarely prescribe a solution of nitrate of silver for the patient's 
own employment, but frequently myself apply it to the vaginal 

1 Pathology and Treatment of Leucorrhoea, p. 183. 



TREATMENT. 183 

walls, by first introducing a glass speculum as far as the cervix uteri, 
and then pouring a few drachms through the instrument. If the 
speculum be slowly withdrawn, the fluid will come in contact with 
the whole extent of the vagina. I regard this method as one of 
special value, for if the patient lie on her back with the pelvis well 
elevated, and if the speculum be as large as the parts will admit, the 
force of gravity carries the solution into every recess of the dilated 
vagina, and insures its thorough application to this canal, and also, 
in a measure, to the cavity of the cervix. The parts should be 
thoroughly cleansed with copious injections of simple water, before 
the speculum is introduced. In this manner, a solution of nitrate of 
silver, containing 9j-iij to the ounce, may be applied by the surgeon 
every third or fourth day, and the patient at the same time use some 
mild astringent injection twice a day. 

An application of the solid nitrate of silver crayon, a favorite 
method of treatment among French surgeons, is requisite in some 
cases which do not improve under a solution of the same salt. The 
deepest folds of the vagina should be exposed by means of a bivalve 
speculum, and the caustic applied to the mucous membrane covering 
the cervix, and to that of the vaginal walls, as they are brought into 
view by the gradual withdrawal of the instrument. The compound 
tincture of iodine, pencilled over the surface, with a camel 's-hair 
brush attached to a long handle, is sometimes preferable to the lunar 
caustic. 

The contact of purulent matter with the mucous membrane of the 
genital organs is doubtless a constant source of irritation, and is 
probably sufficient to account for some of the superficial abrasions 
and other lesions, revealed by a specular examination. The collec- 
tion and retention of pus upon the external integument will soon 
excoriate the surface, and, with still greater reason, may it be sup- 
posed to act thus upon the more delicate mucous membrane. The 
abrasions, once formed, increase the quantity of the discharge by 
their own secretion, and thus the two react upon each other, and 
prolong the disease. The evil is easily remedied in balanitis and 
vulvitis by interposing between the inflamed surfaces some porous 
material, capable of absorbing the discharge as fast as it is secreted, 
and wet, if desired, with an astringent lotion, which will exert a 
constant medicinal effect upon the mucous membrane. The same 
result may be attained in vaginits, and has even been attempted in 
gonorrhoea of the cervix. 1 For this purpose a folded piece of lint 

1 Hourmann, du Tamponnement, comme Me'thode de Traitement des Ecoulements 
Ute'ro-vaginaux. Journal des Connaissances Medico-Chirurg., Mars, 1841, p. 89. 



184 GONORRHOEA IN WOMEN. 

is sometimes used, but a plumasseau of charpie or carded cotton is 
preferable,, since it retains its elasticity to a greater degree, and is a 
better absorbent. To facilitate its withdrawal, a small string may 
be previously attached to it. The size of this tampon must be pro- 
portioned to the dimensions of the vagina in each case, and will 
vary in diameter from half an inch to two inches. In some 
instances, it is medicated ; in others, not. In the former case, the 
medicinal substance may be an absorbent or astringent powder, as 
prepared chalk, subnitrate of bismuth, calamine, tannin, powdered 
alum, etc. ; or, it may consist of any of the lotions which have been 
recommended for the purposes of injections either in the male or 
female. Calamine and powdered alum are the best dry preparations, 
and a solution of tannin in glycerin (3j-ij ad 3j) an excellent fluid 
astringent. The plug may be inserted by the surgeon through a 
speculum, or the patient may be taught to introduce it with her 
finger, or by means of a stylet. It should be withdrawn at the end 
of twelve hours, the vagina washed out with a copious injection, 
and a fresh plug introduced, or the latter may be deferred till the 
following day. 

Scanzoni employs a plug of cotton wool, sprinkled with alum 
powder, either pure or mixed with one or two parts of sugar. Pure 
alum is liable, on the second or third application, to excite a very 
disagreeable sensation of heat and constriction in the vagina, ren- 
dering it necessary to suspend the treatment for a week or two ; 
hence it is not to be used undiluted, unless the parts are quite 
insensible ; and on this account, therefore, it will be best to try, in 
the majority of cases, a mixture of alum and sugar. The plug, thus 
prepared, should not be used offcener than every second or third day, 
nor be allowed to remain in longer than twelve hours, and warm 
water should be injected immediately on its withdrawal. If these 
precautions be neglected, acute inflammation of a troublesome 
character may be excited, and the discharge augmented instead of 
diminished. 1 

Demarquay recommends a plug moistened with a solution of one 
part of tannin in four parts of glycerin. His directions are : first to 
subdue the inflammatory symptoms of the acute stage by appropriate 
regimen, baths, and frequent emollient injections ; next as soon as a 
speculum can be introduced, to inject simple water in large quanti- 
ties, so as to remove all secretion from the vaginal walls, which are 
afterwards to be dried by means of swabs ; and, finally, to introduce 

1 Op. cit., p. 456. 



TREATMENT. 185 

plugs of charpie saturated with the mixture of tannin and glycerin. 
On the following day, the patient should take a bath, the plugs be 
removed, the injections repeated, and fresh plugs introduced. M. 
Demarquay states that he has never found it necessary to renew these 
applications more than four or five times. After discontinuing them, 
astringent injections, consisting of an infusion of walnut leaves, in 
which one drachm of alum to the quart has been dissolved, should 
be used two or three times a day for a week or ten days. 1 The active 
principle of the infusion of walnut leaves, recommended by M. 
Demarquay, is tannin, and a convenient substitute may be found in 
a solution of alum and this vegetable acid in simple water, according 
to the formula previously given. 

Thiry exposes the vaginal walls with a speculum ; cauterizes the 
surface, if much inflamed, with solid nitrate of silver ; then sprinkles 
over it finely powdered charcoal or cinchona, and introduces a 
tampon of cotton wool, which he allows to remain from three to five 
hours. 2 

Simpson, of Edinburgh, has proposed an efficacious mode of 
keeping an astringent in constant contact with the vaginal walls, 
by means of pessaries, prepared according to the following for- 
mulae : — 

R. Acidi tannici ^ij. 

Cerae albae 9 v. 

Axungiae £vi. 
Misce, et divide in Pessos quatuor. 

R. Aluminis gj. 

Pulveris catechu gj. 

Cerae flaveegj. 

Axungiae gvss. 
Misce, et divide in Pessos quatuor. 3 

Hip-baths, taken every morning on 'rising or in the early part of 
the day, are valuable adjuvants in the treatment of chronic vaginitis. 
The temperature of the bath should be determined in part by the 
season of the year, and in part by the strength and habits of the 
patient. It is well to commence with lukewarm water, and gradu- 
ally lower the temperature as the system becomes accustomed to 
them ; but they should never be so cold nor continued so long, that 
the patient feels chilly for some time after their employment, and 
reaction should be promoted by friction with a coarse towel, flesh- 

1 Bulletin de Thgrapeutique, tome i., p. 541. 

2 Journal de Me"d. de Bruxelles, Fev. 1854. 

8 Edinburgh Monthly Journal, June, 1848. and Obstetric Works, p. 98. 



J86 GONORRHOEA IN WOMEN. 

brush or hair-mitten. These baths may be rendered still more 
effectual by the addition of a handful of coarse salt to each bucket 
of water used. Astringents, as alum, in the proportion of half a 
pound to each bath, are also recommended by some authors. 

The hygienic management of the case should always receive special 
attention in chronic vaginitis. As the inflammatory symptoms of 
the acute stage subside, the patient may be allowed a more generous 
diet and greater freedom of motion, but she should still avoid violent 
or prolonged exercise, and especially all sexual excitement. Walk- 
ing and even standing for any length of time should be but moder 
ately practised at this stage of the affection. No absolute rules can 
be laid down for diet, which should be adapted to each individual 
case. In general, the food should be plain and simple, and yet 
sufficiently nourishing, and the meals should be taken at regular 
hours. Highly seasoned dishes, pastry, and meats, cheese and strong 
tea and coffee, should be forbidden ; and bread, eggs, fresh meat 
once a day, vegetables, and simple puddings, recommended. Regu- 
larity of the bowels should be secured, if necessary, by small doses 
of saline cathartics, taken on rising in the morning; and, in brief, 
all such measures should be adopted, as are calculated to bring the 
general health to the best possible condition. The latter rule implies 
that the system should neither be stimulated above, nor depressed 
below, the happy mean ; yet, at the same time, there are but few 
cases of chronic vaginitis which do not require some support, and 
in which either mineral acids, preparations of iron, vegetable tonics, 
quinine, or even stimulants, are not, at some period, indicated. 
There is really no inconsistency in pulling down with, one hand, 
and, at the same time, building up with the other; in applying 
leeches, for instance, to the cervix, and unloading the pelvic vessels 
by cathartics, while tonics are given to elevate the general tone of 
the system. Such a course must often be pursued, especially with 
corpulent women of sedentary habits, whose condition, in spite of 
their apparent excess of health, is in reality below par. I would 
refer the reader to the chapter on gleet, for much that has reference 
to the hygienic management of chronic vaginitis, which is in fact 
the analogue of gleet in man. In both of these affections, constitu- 
tional and local treatment must proceed hand in hand, if any perma- 
nently good result is to be attained. 

The formulas for various tonics, already given when treating of 
this disease in the male sex, are equally applicable to the female. 
The only one which I would add at present is the following old, but 
excellent combination of a tonic, cathartic, and astringent. Its 



TKEATMENT. 187 

cheapness recommends it especially for the poorer class of patients, 
while for those in better circumstances a more palatable substitute 
may be found in Seidlitz powders or citrate of magnesia, taken on 
rising from bed, and in the French dragees of iron administered just 
before or after meals. 

R. Magnesise sulphatis ^iss. 

Ferri sulphatis ^ij. 

Acidi sulphurici gtt. x. 

Infusionis gentianae comp. Oj. 
M. 
A tablespoonful three times a day. 

In gonorrhoea of the vulva lotions may be applied with great facil- 
ity, and the parts separated by the interposition of lint or charpie. 
Cauterization with the solid nitrate of silver or a solution of this 
salt is often beneficial. Resolution of a commencing abscess of the 
vulvo-vaginal gland or duct, may sometimes be obtained by rest, 
cathartics, and antiphlogistic regimen, assisted, in some cases, by the 
application of leeches to some adjacent part. If suppuration takes 
place, the abscess should be opened without delay. Eicord and 
Yidal advise making the incision upon the external surface of the 
labium, to avoid the admission of the urine and discharges, which 
would irritate the cavity of the abscess and prevent its healing. An 
incision in this situation, however, fails to prevent a spontaneous 
opening on the mucous surface, where the abscess naturally tends 
to point. 1 By making a small incision on the internal and inferior 
aspect of the tumor, and directing the knife somewhat upwards so 
that the cut shall be valvular, and also by allowing the abscess to 
evacuate itself by the contraction of its walls without the exercise 
of pressure, the entrance of foreign matter may generally be pre- 
vented. In case the abscess repeatedly recurs, its exact seat should 
be carefully ascertained. If it occupy the duct, it should be laid 
open by a free incision, and the cavity filled up with lint. If it be 
seated in the gland, this must be dissected out. I have tried, in 
several instances, to cure these abscesses by the introduction of a 
seton, but have always failed. 

Whenever, after an attack of vulvitis, there still remains a puru- 
lent discharge from the vulvo-vaginal duct, and also in the cases 
described by Dr. Salmon in which this part is primarily affected, a 
solution of nitrate of silver may be injected by means of Anel's 
syringe. 

1 Huguier, op. cit., p. 343. 



188 GONOKRHCEA IN WOMEN. 

In gonorrhoea of the uterus, the os should be dilated if necessary by 
means of sponge tents, and the cavity of the cervix and body of the 
uterus be freely cauterized with the solid nitrate of silver. A 
crayon of this salt may be passed up with forceps into the uterine 
cavity ; or the extremity of a uterine sound or Lente's probe x may 
be coated with the nitrate melted over a spirit-lamp, and be made to 
sweep over the whole affected surface. No danger need be feared 
even if the crayon of the nitrate should break, and a portion be left 
within the uterus. The application should be repeated every third 
or fourth day, and astringent vaginal injections be still continued. 
Intra-uterine injections are never admissible, as they have repeatedly 
been fatal. 

Whenever, in gonorrhoea of the vagina or uterus, the cervix is 
found enlarged and congested, from four to six leeches may be 
applied. They are especially applicable at the outset of the treat- 
ment, and may require to be repeated once or twice at intervals of 
a week ; but the patient should not be debilitated by their frequent 
use. The surgeon should apply them himself, taking care to plug 
the cervix beforehand, that they may not fasten upon the sensitive 
membrane of its internal surface. If the flow of blood is excessive 
it may be arrested by cold injections of a solution of alum. 

The acute stage of urethritis is of so short duration as to demand 
but little special treatment. In most cases, the measures adopted 
for the concomitant inflammation of the vulva, vagina, or uterus, 
aided, perhaps, by the administration of alkalies, neutral salts, or 
sedatives, are sufficient to effect a decided amelioration, and often 
the entire disappearance of the disease. When this result fails to 
be attained, I do not hesitate to resort to injections, as in urethral 
gonorrhoea in men ; but as they cannot be used by the patient, it is 
necessary for the surgeon to administer them himself. Their active 
principle may be one of the salts of lead or zinc, or tannin ; or from 
one to two drachms of a solution of nitrate of silver, containing ten 
or twenty grains to the ounce, may be thrown in. If, in this case, 
we carefully guard against having the bladder entirely empty, no 
evil result need be feared. Cullerier, in gonorrhoea of the female 
urethra, does not hesitate to cauterize the whole length of the canal 
by means of a crayon of nitrate of silver sufficiently large to distend 
the passage. 2 

1 A new Uterine Porte-Caustique, by Feed. D. Lente, M.D. ; American Med. 
Times, Sept. 26, 1863. 

2 Des Affections Blennorrhagiques, p. 58. 



TREATMENT. 139 

Copaiba and cubebs may also be employed in this affection, 
administered in the manner directed for men. Eicord's experi- 
ments have shown that their effect in gonorrhoea of any portion 
of the genital organs not traversed by the urine is so slight that 
they are not to be recommended in vaginitis or vulvitis. Indeed, 
they can readily be dispensed with in all forms of gonorrhoea in 
women. 



190 GONORRHOEAE- OPHTHALMIA. 



CHAPTER X. 

GONORRHEAL OPHTHALMIA. 

Gonorrheal ophthalmia has been supposed to originate in three 
ways — from inoculation, from metastasis, and from sympathy, each 
of which has from time to time been received by certain authors as 
its exclusive mode of origin. 

The occurrence of gonorrhceal ophthalmia from inoculation or 
contagion, cannot, at the present day, be called in question. • Numer- 
ous cases reported by Mackenzie, by Lawrence, and by nearly every 
modern writer on diseases of the eye, leave no room to doubt that 
the discharge of gonorrhoea applied to the ocular conjunctiva, may 
set up a severe and destructive Torm of inflammation, similar to if 
not identical with purulent conjunctivitis. But, besides these reports 
of cases in which the inoculation has been the result of accident, 
farther proof is to be found in the treatment of pannus — employed 
of late years chiefly by French and German surgeons — in which the 
eyes have been intentionally inoculated with the pus of gonorrhoea. 
Discharges from the genital organs have been transferred to eyes 
affected with pannus, with the express design of exciting acute 
inflammation, which, it was hoped, might cure the chronic disease ; 
and, however questionable may have been the results of this prac- 
tice, so far as the accomplishment of the latter purpose is concerned, 
there has been, at all events, no difficulty in producing acute inflam- 
mation by such inoculation. With these facts before us, therefore, 
no farther doubt of gonorrhoeal ophthalmia from contagion is 
admissible ; indeed, direct inoculation is now regarded by all sur- 
geons, with but few exceptions, as the only mode in which originates 
that destructive form of conjunctivitis which sometimes attends 
gonorrhoea. 

The idea of a metastatic origin of gonorrhoeal ophthalmia was 
first advanced by Saint Yves, who was acquainted with no other 
mode, as appears from his chapter, "Of the Venereal Ophthalmy," 1 

1 A New Treatise of the Diseases of the Eyes, by M. De St. Yves, Surgeon Oculist 
of the Company of Paris, translated from the original French by J. Stockton, M.D., 
London, 1741, p. 168. 



FREQUENCY. 191 

which is so short, quaint, and interesting, that I shall quote it in 
extenso : " This tenth species of ophthalmy has almost the same signs 
with the precedent ('the most dangerous ophthalmy, called che- 
mosis'), with this difference that the conjunctiva, which is swelled, 
appears hard and fleshy. It begins thus : a great quantity of whitish 
matter with a yellowish cast, oozes constantly through the eye. 
This disease, which proceeds from a venereal cause, is very rare ; 
yet I have seen several attacked with it. In most of them, this 
disease appeared two days after the beginning of a virulent gonor- 
rhoea; the matter, not running off by its usual passages, was removed 
to the eye, through which there flowed a like matter, which stained 
the linen in the same manner as when it passed through the usual 
channels." 

Gonorrhceal ophthalmia from metastasis, as here stated, implies 
a translation of the disease from the genital organs to the eye ; 
and, to prove its existence, it would be necessary to produce 
unquestionable instances in which the urethral discharge has 
suddenly subsided or disappeared prior to the inflammation of 
the ocular tunics. But few cases, however, at all likely to fulfil 
these conditions, have been adduced, and even these few have 
been of such doubtful character, that the idea of a metastatic origin 
of gonorrhceal ophthalmia is at the present day almost entirely 
abandoned. 

Still, numerous instances are on record of disease of the eye 
accompanying gonorrhoea, in which the circumstances of the case 
preclude the admission of direct inoculation, and in which the 
symptoms and course of the ophthalmia are decidedly different from 
those of gonorrhceal ophthalmia from contagion. While discarding 
the term metastatic as applied to these cases, many surgeons have 
given them the name of sympathetic ; rather as a convenient expression, 
however, than as really explaining their mode of origin. In the next 
chapter I shall endeavor to show that all those cases which have 
been termed metastatic and sympathetic gonorrhceal ophthalmia, 
are merely a manifestation of gonorrhceal rheumatism, which, like 
ordinary rheumatism, may attack several of the ocular tissues. At 
present, I shall consider gonorrhceal ophthalmia originating in con- 
tagion, and allied to purulent conjunctivitis. 

Frequency. — Gronorrhceal ophthalmia, compared with the fre- 
quency of gonorrhoea, is a rare affection. The following table ex- 
hibits the number of cases received at the N". Y. Eye Infirmary 



192 



GONORRHEAL OPHTHALMIA. 



during a period of fifteen consecutive years, and the proportion 
which these cases bear to the whole number of patients. 



Year. 
1845 
1846 
1847 
1848 
1849 
1850 
1851 
1852 
1853 
1854 
1855 
1856 
1857 
1858 
1859 



Whole Number Cases of Gonorrhceai 


of Patients. Ophthalmia. 


1366 . 


2 


1245 . 


3 


1485 . 


2 


1815 . 


5 


1902 . 


3 


2082 . 


3 


2472 . 


6 


2732 . 


. 7 


2719 . 


5 


2635 . 


6 


2652 . 


5 


2634 . 


. 4 


3216 . 


. 3 


3908 . 


. 2 


4171 . 


. 3 



Total 



37,034 



59 



It thus appears that, compared with the whole number of diseases 
of the eye treated at this institution, cases of gonorrhceal ophthalmia 
are only as 1 to 628. "We have no statistics by which to determine 
the exact ratio of this disease to the whole number of "cases of 
gonorrhoea ; yet I think the experience of every physician would 
lead him to infer that it is not much greater than to diseases of the 
eye, since gonorrhoea must be nearly as frequent as all ocular affec- 
tions combined. 

Causes. — The contagious matter which has produced acute in- 
flammation of the conjunctiva in a given case, may have been 
derived from the genital organs or from the opposite eye — already 
affected with gonorrhceal ophthalmia — of the same, or from those 
of another person. An opinion, originating with Mr. Vetch, 1 pre- 
vailed at one time, that the pus of gonorrhoea was innocuous when 
applied to the eye of the individual secreting it. This surgeon 
drew this conclusion from several unsuccessful attempts which he 
made to inoculate the urethrae of persons suffering from gonorrhceal 
ophthalmia with their conjunctival discharge, in the hope of " divert- 
ing the disease from the eye to the urethra." At the same time he 
succeeded in producing urethritis in another patient by applying to 
his meatus matter taken from the eye of another. The results of 
these experiments, however, have been proved to be worthless, and 



1 A Practical Treatise on the Diseases of the Eye. London, 1820. 



CAUSES 193 

t^e fact is now well established, that the source from which the 
matter is derived does not influence its power of contagion. Id 
many of the reported cases of this disease, the ophthalmia was pro- 
duced by patients washing their eyes with their own urine, with 
which gonorrhceal pus was mixed, or by otherwise applying the dis- 
charges from their own persons. 

The personal habits of those affected with gonorrhoea, and the 
degree of intimacy existing between members of the same house- 
hold, will, in a great measure, determine the frequency of infection. 
Among the poor and squalid, where cleanliness is neglected and the 
same vessels and towels are used in common, gonorrhceal ophthalmia 
may readily be communicated from one individual to another, until 
it has attacked all the members of the same family. 

Kicord states that he has never seen gonorrhceal ophthalmia pro- 
duced by discharges from any portion of the genital organs except 
the urethra ; and that he has never known it to be caused by the 
pus of balanitis or vaginitis. There is reason to believe, however, 
that a simply vaginal discharge is capable of exciting the disease 
under consideration. 

It is a well established fact that " ophthalmia neonatorum " is fre- 
quently caused by inoculation of the infant's eyes with leucorrhoeal 
discharges from the mother. I have repeatedly seen severe puru- 
lent conjunctivitis in very young girls, who were affected with that 
form of vaginitis which sometimes attacks children, independently 
of contagion, and which has been so ably treated of by Mr. Wilde, 
of Dublin. Analogous cases are reported in treatises on diseases 
of the eye, and Dr. Jiingken mentions one instance, in which the 
ophthalmia, originating in this manner, spread to seven members of 
a family. 1 

I know of no authentic case of gonorrhceal ophthalmia occasioned 
by the pus of balanitis. Matter from a venereal or ordinary abscess 
must also be regarded as generally innocuous. Yet it is, perhaps, 
impossible to determine with accuracy the limits within which puru- 
lent matter is capable of exciting severe inflammation of the con- 
junctiva. The predisposition of the person exposed will doubtless 
have no small influence upon the effect produced. Still, so far as at 
present known, these limits are confined to the urethra and vagina. 

The inoculations which have been employed in the treatment ol 
pannus, will throw some light upon the conditions under which 
contagion may be supposed to take place. The puriform matter 
used in these inoculations has been derived either from the genital 

1 Annales d'Oculistique, 8 e s6rie, t. ler, p. 355. 
13 



194 GONORRHEAL OPHTHALMIA. 

organs, or from an eye affected with gonorrheal ophthalmia, or 
ophthalmia neonatorum. When such matter is kept from contact 
with the air, it is found to retain its contagious property for about 
sixty hours. If exposed to the air, and allowed to dry, it soon be- 
comes innocuous. In the experiments of M. Piringer, of Gratz, a 
piece of linen was moistened with gonorrhoeal matter, and allowed 
to dry; the cloth was then rubbed upon the eyes of several persons, 
and no inoculation ensued. The dried matter scraped from the 
cloth, and applied directly upon the conjunctiva, took effect within 
about thirty-six hours after it was first obtained. Matter, once dried 
and immediately moistened again, either by the addition of water or 
by contact with the secretions of the eye, was found to be con- 
tagious. Fresh matter was contagious, even when diluted with one 
hundred parts of water. 

Van Eoosbroeck experimented with the pus of a common ab- 
scess, and found that it was innocuous when applied to the eye. 
This surgeon was also led to the conclusion that the discharge from 
an eye affected with purulent ophthalmia, diluted with water, retains 
its power of contagion until decomposition has begun to take place, 
as shown by its evolving the odor of putrefaction. 

When the inoculation is successful, no disagreeable sensation is 
at first excited by the application of the matter ; and no effect is 
perceived until after the lapse of from six to thirty hours, when the 
eye begins to feel hot, and there is an increase in the ocular secre- 
tions, which are at first entirely mucous, but soon become muco- 
purulent. 

Gonorrhoeal ophthalmia is much more common in men than in 
women. Ricord ascribes this difference to the greater frequency of 
urethritis in the male, this being the only form of gonorrhoea, capa- 
ble, as he supposes, of occasioning gonorrhoeal ophthalmia. I have 
already dissented from this opinion of Eicord, and I believe that so 
far as any explanation can be given of the difference in the relative 
frequency of its occurrence in the two sexes, it must be based upon 
their different habits. 

Symptoms. — Gonorrhoeal ophthalmia may occur at any stage of 
an attack of gonorrhoea, although it is said to be more frequent 
during the decline. The urethral or vaginal discharge is doubtless 
most contagious when most purulent, which is during the acute 
stage, but the short duration of this stage affords less opportunity 
for it to be applied to the eye than the longer stage of decline. At 
first, the disease usually attacks one eye alone. It may remain con- 



SYMPTOMS. 195 

fined to this eye, but not unfrequently, after the lapse of a few days, 
the opposite eye becomes implicated. 

The symptoms of gonorrhoeal ophthalmia are, in the main, iden- 
tical with those of purulent conjunctivitis. The former disease, 
however, is more rapid in its development, and even more destruc- 
tive to sight than the latter. 

The earliest indications of an attack of this disease are an itching 
sensation just within or on the margins of the lids, a feeling as if 
some foreign body were in the eye, and an increase in the ocular 
secretions. The latter retain at the outset their normal transparency, 
although they appear unusually viscid ; the cilise become adherent 
and glued together, and a collection of dried mucus may be seen at 
the inner canthus. As the disease progresses, the vessels underly- 
ing the conjunctiva become distended with blood. They may at 
first be distinguished from each other as in simple conjunctivitis, 
but they are soon lost in a uniform red appearance of the globe, 
extending as far as the cornea; which retains its normal transpa- 
rency. The conjunctiva is also found to be somewhat elevated 
above the sclerotica by an effusion of serum, and its surface is 
roughened by the development of its papillae. Meanwhile, the dis- 
charge has become purulent, and is secreted abundantly from the 
inflamed surfaces. 

An attack of gonorrhoeal ophthalmia is so rapid in its progress, 
that the early symptoms just now described may have passed away 
before the first visit of the surgeon, who is often called to see his 
patient only after the full development of the disease. He probably 
finds him sitting up, his head bent forwards, his chin resting on his 
breast, and his handkerchief applied to his cheek to absorb the 
discharge, which irritates the surface upon which it flows. The eye- 
lids are swollen, especially the upper, which slightly overlaps the 
lower, and is of a reddish or even dusky hue. The patient states 
that he is unable to open the eye. His inability to do so is caused 
less by an intolerance of light, than by the mechanical obstruction 
which the swelling of the lids occasions, and by the pain which is 
excited by any friction of the inflamed surfaces upon each other. 

The surgeon now moistens the edges of the lids with a rag dipped 
in warm water in order to facilitate their separation, and proceeds 
with his examination. In his attempt to open the eye, he is careful 
not to make pressure upon the globe, in order to avoid giving unne- 
cessary pain, and also, lest the cornea, if already ulcerated, may be 
ruptured, and the contents of the globe escape. With one finger 
placed just below the eye, he slides the integument downwards over 



196 GONORRHEAL OPHTHALMIA. 

the malar bone, and thus everts the lower lid ; the upper lid being 
elevated by a similar manoeuvre with the other finger of the same 
hand applied below the edge of the orbit ; or, again, he may expose 
the globe by seizing the lashes of the upper lid with the thumb and 
finger and drawing the lid forwards and upwards. All this may be 
accomplished with the left hand, the right being left free to wipe 
away the discharge, or to make applications to the eye. 

As soon as the lids are separated, .a quantity of thick, yellowish 
pus wells up between them and ' partially obstructs the view ; the 
swollen palpebral conjunctiva, compressed by the spasmodic action 
of the orbicularis muscle, may also project in folds. The collection 
of matter is now removed with a soft, moist sponge or rag, and the 
surface of the ocular conjunctiva exposed. This membrane is found 
to be of a uniform red color, with its vessels undistinguishable from 
each other, and elevated above the sclerotica by an effusion of serum 
and fibrin in the cellular tissue beneath it. This swelling of the 
conjunctiva is seen to terminate at the margin of a central depres- 
sion occupying the position of the cornea, and filled with a collection 
of the less fluid constituents of the puriform discharge, which may 
at first sight be mistaken for the debris of a disorganized cornea. 
On removing this matter, however, the latter structure may still be 
found clear and transparent, at the bottom of the depression, where 
it is overlapped by the swollen conjunctiva. In less fortunate cases, 
it may have become hazy from the infiltration of pus between its 
layers, or ulceration may have already commenced. If an ulcer is 
not evident on first inspection, it may often be discovered at the 
margin of the cornea by gently pushing to one side the overlapping 
fold of conjunctiva. Meanwhile, the secretion of pus is constantly 
going on and requires repeated removal. It is astonishing to ob- 
serve how large a quantity of this fluid can be secreted by so limited 
a surface. This secretion has been estimated at more than three 
ounces per day. 

The amount of pain, occasioned by this disease, varies in different 
cases. During the development and acme of the inflammation, it is 
generally severe. It is described by the patient as a sensation of 
burning heat and tension in the eyeball, radiating to the brow and 
temple. The system at large sympathizes with the local disease. 
For a time there may be general febrile excitement, but symptoms 
of depression soon appear ; the pulse becomes rapid and irritable, 
the skin cold and clammy, and the patient anxious and nervous. 
This depression of the vital powers is not invariably met with, but 
is the most frequent condition of the patient, after the disease has 



SYMPTOMS — DIAGNOSIS. 197 

continued for a few days ; and it may occur even at an earlier period 
when the health has been previously impaired by any cause. 

Notwithstanding the severity of the symptoms, resolution is still 
possible. Under proper care and treatment, the inflammatory action 
may abate, and the tissues recover their normal condition, leaving 
the eye as sound as before the attack. So fortunate a result, how- 
ever, is more to be hoped for than confidently anticipalfed. The 
chances of success are greater when the case is seen at an early 
period, before the effusion beneath the conjunctiva has been rendered 
firm by a deposit of fibrin, or before ulceration of the cornea has 
commenced. The latter is the chief danger to be feared. Ulcera- 
tion usually commences at the margin of the cornea, and may extend 
around its circumference, or advance towards its centre. It is in 
some cases superficial ; in others, it penetrates through the whole 
thickness of the cornea, and prolapse of the iris ensues, or more or 
less of the contents of the globe escapes. Sometimes a portion or 
the whole of the corneal membrane becomes disorganized, and comes 
away en masse. The eye has been known to be destroyed in this 
manner within twenty -four hours after the first symptoms of the 
disease were observed, and this catastrophe is said to have occurred 
in a single night, in a case at the New York Hospital. The escape 
of the aqueous humor, and other contents of the globe, is usually 
followed by an amelioration of the pain, and the pattent often enter- 
tains the hope that he is improving, while the surgeon knows that 
his sight is irretrievably lost. 

The amount of permanent injury inflicted upon the eye will 
depend upon the extent and situation of the ulceration. "When the 
latter has been superficial, and situated near the margin of the cornea, 
the resulting opacity will not interfere with vision, and even when 
the leucoma is central, an operation for artificial pupil is still prac- 
ticable, if any portion of the cornea remain clear. Perforation of 
the anterior chamber and prolapse of the iris, when partial, may also 
be remedied by art ; but when the whole, or the larger portion of 
the cornea has sloughed away, and the prolapsed iris has become 
covered with a dense layer of fibrin, forming an extensive staphy- 
loma, the case is hopeless. 

Diagnosis. — Independently of the history of the case, we have no 
means of distinguishing gonorrhceal ophthalmia from severe purulent 
conjunctivitis. It has been asserted that the former commences in 
inflammation of the ocular conjunctiva, while the latter first affects 
the lining membrane of the lids. Even if this were true, it would 



198 GONORRHEAL OPHTHALMIA. 

afford but little assistance in the diagnosis, since we are rarely 
enabled to watch the early symptoms. 

Dr. Hairion, 1 Professor of Ophthalmology at the University of 
Lou vain, supposed he had discovered a diagnostic sign of gonorrhoeal 
ophthalmia in the presence of a bubo in front of the ear; bat as no 
one else ever saw such buboes in this disease, the statement must be 
regarded as a sad instance of obliquity of vision produced by pre- 
conceived notions as to the nature of the disease. 

Treatment. — In undertaking the treatment of a case of gonor- 
rhoeal ophthalmia, it is of the first importance that the patient be 
intrusted to the care of an intelligent, careful, and faithful nurse, 
whose whole time and attention can be devoted to carrying out the 
surgeon's directions. This disease is so rapid in its progress, that 
neglect for a few hours only may prove fatal to vision ; if the eye be 
saved, a large share of the credit will be due to the faithfulness of 
the attendant. It hardly need be said that the light touch and gentle 
hand of a devoted woman should be secured, if possible. 

The directions of the surgeon should vary according to the stage 
of the disease. If the inflammation has commenced within a few 
hours only, and has not as yet attained its height, from four to six 
leeches may be applied near the external canthus of the affected eye, 
or a number of* them be made to attach themselves to the mucous 
membrane of the corresponding nostril. If leeches are not at hand, 
cups to the temples will suffice. Such local depletion may generally 
be repeated with benefit, for a day or two, once or twice in the 
twenty-four hours, especially if the patient be of full habit. If, 
however, the disease progresses unchecked, and especially if there 
be any symptoms of general depression of the system, even this 
slight abstraction of blood should be avoided. It is adapted only to 
the early stage of the inflammation, and, at a later period, is useless, 
if not positively injurious. 

A free purge should be administered, as, for example, five grains 
of calomel followed by half an ounce of castor oil, a full dose of 
Epsom salts, or three "compound cathartic pills." With regard 
to the diet of the patient, much will depend upon his general con- 
dition. As a general rule at this early stage, it should be light, 
consisting of gruel, broths, etc. ; at the same time it is important to 
recollect the tendency in this disease to depression of the vital 
powers, and to be governed by the indications of each individual 
case. 

1 Annates d'Oculistique, t. xv., p. 169. 



TREATMENT. 199 

Lastly, but by no means of least importance, the directions- which 
will presently be given for the frequent cleansing of the eye, should 
be insisted on, and a collyrium of nitrate of silver, ten grains to the 
ounce, should be dropped between the lids every two hours, or every 
bour in threatening cases. 

The treatment above recommended is intended for the early stage 
of gonorrhoeal ophthalmia, before much chemosis, swelling of the 
lids, or other severe symptoms have set in. In most cases, however, 
as already stated, the surgeon does not see his patient till the disease 
has attained its height, when some modification of the above treat- 
ment is required. 

Leeches and cups can now rarely be used to advantage. At the 
best, they will be impotent to stay the progress of the inflammation. 
Cathartics should be given as in the first stage, 1 and one or two free 
evacuations from the bowels secured each day. Here again the 
general condition of the patient will in a measure determine the diet 
to be recommended ; but in the great majority of cases nourishment 
should be administered as freely as the appetite will admit, and may 
consist of bread, milk, beef-tea, steaks, mutton, eggs, etc. When 
the patient is unable to eat, and especially if his skin is found to be 
cool and his pulse irritable, or again, if ulceration of the cornea has 
already commenced, we must resort to stimulants and tonics. These 
are almost always required in this stage of the disease in hospital 
practice, where patients are generally more or less cachectic, and 
even in private practice the subjects of gonorrhoeal ophthalmia are 
often run down by an irregular course of life. Nothing will so much 
contribute to hasten destructive ulceration of the cornea as a low 
state of the vital powers. The least indication of this condition 
should be met by quinine, ale, porter, wine, or milk-punch, freely 
administered. 

The room occupied by the patient should, if possible, be spacious, 
dry, and well ventilated. The eyes may be protected from a glare 
of light by the position of the patient, or by a pasteboard shade, or 
by curtains ; but the room should not be entirely darkened, as the 
complete exclusion of light favors congestion of the eye. With 
still stronger reason, should the eyes be uncovered and kept free 
from poultices, alum-curds, tea-leaves, raw oysters, or similar appli- 
cations, which are often recommended by some officious acquaint- 
ance. No surer way of destroying the sight could be devised than 
by using these articles. 

1 When the disease has already made considerable progress before the surgeon is 
called, an active cathartic, as croton oil, should be selected. 



200 GONORRHEAL OPHTHALMIA. 

When chemosis has already taken place, no time should be lost 
in dividing the conjunctiva and the subjacent cellular tissue by 
means of a scarificator, bistoury, or scissors, and the operation 
should be repeated once or more frequently during the twenty -four 
hours, so long as the chemosis continues. The late Mr. Tyrrell ad- 
vised radiated incisions between the courses of the recti muscles, on 
the supposition that ulceration of the cornea was due to constriction 
of the conjunctival vessels exercised by the chemosis, which it was 
desirable to relieve without cutting off the vascular supply by 
dividing the larger vessels. Experience, however, has shown that 
his theory was incorrect, and that as much benefit accrues from 
simply snipping the conjunctiva and underlying cellular tissue 
wherever it is puffed up by infiltration, and promoting the flow of 
blood by the application of warm water. Within half an hour after 
the blood has ceased to flow, the whole inflamed surface should be 
freed from pus and brushed over with a camel's-hair pencil dipped 
in a solution of nitrate of silver containing forty to sixty grains to 
the ounce, or the solid crayon may be applied, taking care to remove 
the residue by a free application of tepid water afterwards. 

At the first visit, also, the attendant, who is to take charge of the 
case, should be instructed as to her duties, and the importance of her 
faithfully performing them. She should be made to look on while 
the surgeon goes through the process of opening and cleansing the 
eye, and be taught to follow his example. A syringe is sometimes 
recommended for the purpose of removing the pus. There are, 
however, two objections to the employment of this instrument : in 
the first place, unless used with gentleness, the force of the stream 
irritates the inflamed and sensitive conjunctiva ; and, again, the 
injected fluid, mixed with contagious matter, may be reflected back, 
and strike the eye of the attendant or fall upon the opposite eye of 
the patient. Several cases are recorded in which this accident has 
occurred. For these reasons a soft rag is to be preferred, and this, 
again, is better than a sponge, because it is more cleanly and may be 
frequently changed. By squeezing the fluid from the rag upon the 
adherent portions of the discharge, or by gently touching them with 
a free fold of the cloth projecting beyond the fingers, they can readily 
be detached. Simple tepid water may be used for these ablutions, 
but I prefer a solution of alum, of the strength of a drachm to the 
pint. The nurse should be directed to repeat them every hour or 
every half hour, according to the severity of the case, and the patient 
may be furnished with a cupful of the solution to bathe the external 
surface of the eye and wash away the discharge, still more fre- 



TREATMENT. 201 

quently. Cleanliness may be still farther promoted by cutting off 
the cilias, so as to prevent their becoming incrusted with matter ; 
and by smearing the edges of the lids with simple cerate. 

The strong solution of nitrate of silver, already mentioned, may 
be reapplied by the surgeon twice a day when he makes his visits, 
but, meanwhile, a weaker solution of the same salt, containing ten 
grains to the ounce, should be dropped into the eye, after it is 
thoroughly cleansed, every two or three hours. The frequency, 
however, of the application should depend upon the condition of the 
parts and the effect produced. No routine practice is admissible. 
The patient must not be deprived of sleep by too frequent repetition 
of these measures during the night, but he should be provided with 
a watcher, who will cleanse the eye and apply the solution of nitrate 
of silver every few hours. If necessary, sleep must be promoted by 
the administration of an opiate. 

The time has gone by, when mercurials were thought requisite in 

this disease, on account of its supposed syphilitic origin. The only 

circumstance which can justify their employment is the presence of 

a firm, fleshy chemosis, which, owing to its consistency, cannot be 

relieved by incisions. In such cases, mercurials may perhaps hasten 

the absorption of the fibrinous deposit ; but they should be used 

with great caution, especially when ulceration of the cornea has 

already commenced, and should never be pushed to salivation. An 

excellent formula, combining the "gray powder" with quinine, is 

the following : — 

R. Hydrarg. cum creta gr. ij. 
Quiniae sulphatis gr. j-iv. 
Misce et ft. pulv. 
One to be taken morning and night. 

When only one eye is affected, the greatest care should be taken 
to avoid inoculation of the other by allowing the discharge to come 
in contact with it. On the slightest indication of inflammation in 
the latter, the weaker solution of nitrate of silver should be applied 
to it, as frequently as to the eye first affected. 

"When there is excessive oedema of the lids, it may interfere with 
opening the eye and cause pressure upon the globe ; in which case 
relief may be given by puncturing the skin in several places with 
a lancet. Division of the external canthus, in order to facilitate the 
exposure of the inflamed conjunctiva, has been recommended by Mr. 
France 1 and others, but it is not generally required. 

1 Guy's Hospital Reports, third series, vol. iii. 



202 GONORRHEAL" OPHTHALMIA. 

As the symptoms improve, the stronger solution of nitrate of silver 
may be omitted, and the weaker applied less frequently. When 
the chief danger is passed, the collyrium may often be changed with 
benefit, and one of the following substituted: — - 

R. Zinci sulphatis gr. ij. 

Glycerin gij. 

Vini opii 3J. 

Aquae £v. 
M. 

R. Acidi gallici gr. x. 

Glycerin ^iij. 

Vini opii gij. 

Aquae camphorae q. s. ad Jiv. 
M. 

A pleasant method of employing these collyria is by means of an 
eye-cup. I have met with cases in which a solution of nitrate of 
silver appeared to irritate the eye, and in which the above collyria 
were found preferable even in the acute stage of the "disease. 

The occurrence of an ulcer upon the cornea is of serious moment, 
and the friends of the patient should be informed of the danger to 
vision. 

The progress of the ulcer may sometimes be arrested by gently 
touching its surface with a stick of nitrate of silver, the point of 
which has been rounded off and somewhat sharpened by rubbing it 
upon a wet rag ; or a saturated solution of the same salt may be 
applied with a fine camel's-hair pencil. The whitening of the sur- 
face which follows the application will indicate whether the whole 
of the ulcer has been touched. At the same time the pupil should 
be dilated by dropping a solution of atropine upon the globe several 
times a day, or by smearing extract of belladonna, moistened with 
glycerin, around the orbit. The former is much more cleanly. The 
usual strength of the solution employed is two grains to the ounce. 
The object of thus dilating the pupil is to diminish the prolapse of the 
iris if the ulcer should penetrate through the cornea, and, if possible, 
to prevent the pupil's becoming involved in the resulting synechia. 
The chances of accomplishing this are not very great, for a pupil 
dilated by mydriatics contracts as soon as the aqueous humor 
escapes, as is seen during the operation of extraction for cataract • 
still, as the evacuation of the contents of the anterior chamber in 
perforating ulcer of the cornea is often sudden, some hope may be 
entertained of limiting the prolapse. I would again remind the 



TREATMENT. 203 

reader of the importance of avoiding antiphlogistic remedies and 
of the necessity of supporting the strength, when the cornea, a tissue 
of low vitality, is attacked by the ulcerative process. Cupping, 
leeching, low diet, and mercurialization will be sure to hasten 
destruction of the eye, which can only be saved, if saved at all, by 
generous living, stimulants, and tonics. 

A granular condition of the palpebral conjunctiva is frequently 
left after an attack of gonorrhoeal ophthalmia, and may keep up a 
slight discharge and irritation of the eye for a considerable time. 
The best means for its removal consists in the application of a crystal 
of sulphate of copper to the everted lids every second or third day ; 
and the general system should, at the same time, be supported by 
fresh air, good diet, and tonics. 

When a staphyloma has formed, its friction against the lids is often 
a source of irritation to the affected eye, and, through sympathy, to 
its fellow. If it is small, there may be hope of its contracting and 
being less prominent, as the fibrin covering it becomes more firmljr 
organized ; and it may be pencilled over daily with a strong solution 
of nitrate of silver with a view of favoring this result. When, 
however, it has already attained considerable size, and covers so 
large a portion of the cornea that there is no chance of the eye 
serving as an organ of vision in future, it is useless to make any 
farther attempts to save the eye, especially as its inflamed condition 
endangers the integrity of its fellow, and the intraocular pressure 
will probably still farther increase the size of the staphyloma, until 
it bursts of itself or is relieved by art. Two operations are available 
under these circumstances : one, the ordinary excision of the staphy- 
lomatous projection and sinking of the eye ; the other, extirpation 
of the globe by the modern or Bonnet's method. 

The former is to be preferred, as a general rule, in case3 of sta- 
phylomata following gonorrhoeal ophthalmia, because the staphyloma 
is usually limited to the cornea, and the deeper tissues of the eye 
are commonly, though not always, sound. Moreover, the mobility 
of an artificial eye is greater when worn upon a sunken globe, than 
when the latter is removed ; and, again, patients, through ignorance 
of the simple modern operation for extirpation, are very averse to 
its performance. At the same time, it should be recollected that a 
sunken eye, especially when irritated by wearing a glass substitute, 
may at any future period become inflamed and endanger the integ- 
rity of its fellow through sympathy. After the removal of a sta- 
phyloma, therefore, patients should always be warned of this 



204 GONORRHEAL OPHTHALMIA. 

danger, and cautioned to seek advice at once, if ever the stump 
should become inflamed, or the sight of the fellow eye should begin 
to fail. 1 

The operation for removing a staphyloma is too well known to 
require description here. There is only one point to which I desire 
to call attention. After the operation, the lids should be closed by 
strips of isinglass plaster and remain so until the wound has entirely 
healed ; otherwise the friction of the lids and the exposure of the 
hyaloid membrane to the air, will be likely to set up inflammation 
in the deeper tissues of the eye and cause much suffering. 

Extirpation of the globe should be preferred, when internal or 
general ophthalmia has supervened ; when the staphyloma includes 
not only the cornea but a portion of the sclerotica ; or when hemor- 
rhage has taken place from the bottom of the eye, either on the 
perforation of the anterior chamber, on the bursting of the sta- 
phyloma, or during an operation for its removal. The blood, in 
these cases, comes chiefly from the choroidal vessels ; its flow may 
be arrested, but the clot can only be eliminated by the slow and 
tedious process of suppuration, and it is better to remove the eye 
at once. 

The modern operation for extirpation of the globe is exceedingly 
simple. The ball of the eye is alone removed, while the remaining 
contents of the orbit are left. The instruments required are a pair 
of toothed forceps, blunt-pointed straight scissors, and a strabismus 
hook. The eye should be kept open with a wire speculum. The 
conjunctiva and underlying fascia are divided close around the 
margin of the cornea, and the tendons of the four recti muscles 
hooked up and severed as in an operation for strabismus. The 
scissors are then passed in behind the globe and the optic nerve cut 
at its point of entrance, when the ball may readily be removed, after 
dividing the oblique muscles and any remaining points of attach- 
ment. There is no danger of subsequent hemorrhage. The lids 
may be allowed to close, and the clot which forms within them is 
the best hemostatic for such cases. If the operation has been well 
performed, without extending the incisions beyond the ocular fascia, 
the wound will heal with great rapidity. I have frequently been 

1 Calcareous deposit is very liable to take place in sunken globes which have 
become the seat of chronic inflammation, and in such cases it is impossible to relieve 
the irritation except by extirpation. I have this day removed the stump of an eye, 
destroyed by granular conjunctivitis, in a boy aged 16, in which I found a plate of 
calcareous matter the size of a three cent piece. 



TREATMENT. 205 

uble to insert an artificial eye on the third or fourth day after the 
operation. 1 

The remedies recommended in the preceding pages for gonorrhoeal 
ophthalmia may be recapitulated, in the order of their importance, 
as follows : cleanliness, frequent application of an astringent solu- 
tion, nourishment, and, in most cases, stimulants and tonics, incisions 
of the chemosed conjunctiva, cathartics, and local depletion. This 
plan of treatment differs widely from the copious and repeated 
venesections, the low diet, and the free administration of mercurials 
and tartar emetic, prescribed by nearly all writers on this affection 
until within a very few years. If the practice which I have advised 
were new, it might be requisite to say something farther in its de- 
fence ; but its claims have already been established by most of the 
eminent authorities of what may be called the modern school of 
ophthalmic surgery. When supported by the writings and practice 
of such men as Prof. Graves, 2 Critchett, 3 Bowman, "Wilde, Dixon, 4 
France, 5 Hancock, 6 and others, both in this country and abroad, it 
is unnecessary to say anything farther in its favor. I will only add 
that my own experience, drawn from the largest infirmary for dis- 
eases of the eye in this country, perfectly coincides with that of the 
authors above mentioned. 7 

In the words of Mr. Dixon : " The student ought constantly to 
bear in mind that, although the disease termed purulent ophthalmia 
has received its name from that symptom which readily attracts 
notice, namely, the profuse conjunctival discharge, the real source 
of danger lies in the cornea; and that, even if it were possible so to 
drain the patient of blood as materially to lessen or even wholly 

1 It would be out of place in this work to enter more fully into the details of this 
and other operations which may be required after gonorrhoeal ophthalmia. For 
farther particulars with reference to extirpation of the globe, the reader is referred 
to an essay by Mr. Critchett, in the London Lancet (Am. ed.), Jan., 1856; also to 
papers by Dr. C. R. Agnew and by the author, in the N. Y. Journal of Med., Jan. 
and May, 1859. 

2 London Medical Gaz., vol. i., 1838-9, p. 361. 

3 Lectures on Diseases of the Eye, London Lancet (Am. ed.), Aug. 1854. 
* Guide to the Practical Study of Diseases of the Eye. London, 1859. 

6 Op. cit. 6 London Lancet, Nov. 1859. 

7 Dr. O'Halloran appears to have been one of the first to discard the old depletive 
treatment of purulent ophthalmia. In his " Practical Remarks on Acute and Chronic 
Ophthalmia, and on Remittent Fever" (London, 1824), he says: "I am of opinion 
that if any inquiry be instituted amongst the army surgeons, it will be found that 
those who used the greatest depletion were the least successful practitioners, and 
that sloughing, ulcers, &c, more frequently succeeded the evacuating plan than 
when the patient was partly left to nature." 



206 GONORRHEAL OPHTHALMIA. 

arrest the discharge, we might still, fail to save the eye. It is not. 
the flow of pus or mucus, however abundant, that should make us 
anxious, but the uncertainty as to whether the vitality of the cornea 
be sufficient to resist the changes which threaten its transparency. 
These changes are two-fold — rapid ulceration and sloughing. Now, 
has any sound surgeon ever recommended excessive general bleed- 
ing and salivation as a means of averting these morbid changes from 
any other part of the body except the eye ? And if not, why are 
all the principles which guide our treatment of other organs to be 
thrown aside as soon as it attacks the organ of vision?" 



GONORRHEAL RHEUMATISM. 207 



CHAPTER XI. 

GONORRHEAL RHEUMATISM. 

Gonorrheal rheumatism was first recognized by Swediaur, who 
described it under the name of " Arthrocele, Gonocele, or Blennor- 
rhagic Swelling of the Knee." 1 Since Swediaur's time, this disease 
has received particular attention from various writers on venereal 
and diseases of the joints, among whom Sir Benjamin Brodie, 2 'Sir 
Astley Cooper, 8 Ricord, 4 Bonnet, of Lyon, 5 Foucart, 6 Brandes, 7 and 
Rollet, 8 are especially worthy of mention. During this period, how- 
ever, gonorrhoeal rheumatism has by no means been allowed to retain 
its place in the nosological system undisturbed, and there have been 
many who have attempted to explain it away, on various hypotheses. 
Its claims to be considered a distinct complication of gonorrhoea 
will appear in the course of this chapter. 

To an observer who had never heard of the connection between 
gonorrhoea and rheumatism, it might indeed appear a mere coinci- 
dence, if a patient suffering . from gonorrhoea should suddenly be 
seized with inflammation of the joints; but should this same patient, 
after entirely recovering from both affections, and after several years 
of perfect health, again contract gonorrhoea, and again be seized 
with articular rheumatism, the occurrence would be sufficiently 
remarkable to excite a suspicion in the mind of the most careless 
observer that there was some connection between the two. Let this 
second attack be followed by a third, fourth, and fifth, and the sus- 

1 A Complete Treatise on the Symptoms, etc., of Syphilis, by F. Swediaur, M. D. 
Translated from the fourth French edition, by Thomas T. Hewson. Philada., 1815, 
p. 108. 

2 Brodie's Select Surgical Works : Diseases of the Joints. Philada., 1847. 

3 Lectures on the Principles and Practice of Surgery. London, 1835, p. 482. 
* Notes to Hunter, 2d ed. Philada., 1859, p. 275. 

6 Traite" des Maladies Articulaires. Paris, 1853, t. i. p. 376. 

6 Quelques Considerations pour servir a l'Histoire de l'Arthrite Blennorrhagique; 
in 8vo., pp. 45. Bordeaux, 1846. 

7 Archives G6ne>ales de Medicine, Sept., 1854. 

8 Annuaire de la Syphilis ; annee 1858, Lyon. 



208 GONORRHEAL RHEUMATISM. 

picion would be converted into a very strong probability. Suppose 
that numerous other patients were met with, in whom these two 
affections thus repeatedly coexisted, an attack of gonorrhoea in each 
of them being followed by one of rheumatism, with such certainty 
that the latter might be predicted immediately on the appearance of 
the former, and a manifest relation between the two diseases could 
no longer be doubted. Now, this repetition of these two diseases 
in the same person is not merely hypothetical — it is a reality ; and 
it is observed in subjects entirely free from any rheumatic diathesis, 
who have inflammation of the joints at no other time than when 
they have gonorrhoea. Among the many cases which might be 
cited, none perhaps will better illustrate this point than the follow- 
ing, which I quote from the lectures of Sir Astley Cooper : — 

"' I will give you," says this distinguished surgeon, " the history of 
the first case I ever met with ; it made a strong impression on my 
mind. An American gentleman came to me with a gonorrhoea, and 
after he had told me his story, I smiled, and said : do so and so 
(particularizing the treatment), and that he would soon be better ; 
but the gentleman stopped me, and said, ' Not so fast, sir ; a gonor- 
rhoea with me is not to be made so light of — it is no trifle ; for, in a 
short time you will find me with inflammation of the eyes, and in a 
few days, I shall have rheumatism in the joints ; I do not say this 
from the experience of one gonorrhoea only, but from that of two, 
and on each occasion I was affected in the same manner.' I begged 
him to be careful to prevent any gonorrhoeal matter coming in con- 
tact with the eyes, which he said he would. Three days after this I 
called on him, and he said, ' Now you may observe what I told you 
a day or two ago is true.' He had a green shade on and had 
ophthalmia in each eye ; I desired him to keep in a dark room, to 
take active aperients, and apply leeches to the temples. In three 
days more he sent for me, rather earlier than usual, for a pain in 
one of his knees ; it was stiff and inflamed ; I ordered some appli- 
cations, and soon after the other knee became inflamed in a similar 
manner. The ophthalmia was with great difficulty cured, and the 
rheumatism continued many weeks afterwards." 

Similar cases are related by nearly every author who has written 
on this affection, and, further on, many are given in a table of the 
diseases of the eye which accompany gonorrhoeal rheumatism. M. 
Rollet relates in detail five such instances occurring in his own 
practice, and this repetition took place in eight of thirty -four cases 
reported by Brandes, of Copenhagen, and in three of eight cases 
observed by M. Diday. According to Rollet's researches, this repe- 



CAUSES. 209 

tition lias been noted in nearly one-quarter of the total number of 
cases of gonorrliceal rheumatism which have been published. 

The frequency of cases like these can leave no doubt in the 
mind that a close relation exists between these two affections, and 
additional evidence is found in the fact that the rheumatism 
attendant upon gonorrhoea presents certain peculiarities, which, in 
general, are sufficient to distinguish it from the ordinary forms of 
rheumatism. 

Causes. — In comparison with the great frequency of gonorrhoea, 
gonorrhceal rheumatism is exceedingly rare. Very little is known 
of the causes which occasion it in the few, while the many affected 
with gonorrhoea escape. Its occurrence might naturally be attributed 
to a rheumatic diathesis, especially as the fact is well established 
that persons subject to rheumatism are particularly prone to contract 
gonorrhoea ; and it is distinctly asserted by several writers that a 
constitutional tendency to rheumatism is a predisposing cause of 
inflammation of the joints during an attack of gonorrhoea. There 
is reason to believe, however, that the plausibility of this opinion, 
founded on a priori reasoning, has given it greater weight than it 
deserves. Those who have expressed it, have failed to produce any 
evidence in its support ; and if we examine the published cases of 
this disease, we frequently find it noted that the patient never 
suffered from rheumatism except when he had gonorrhoea. M. 
Eollet has made this point a special "subject of inquiry, and states 
that in the great majority of cases of gonorrhceal rheumatism which 
have come under his observation, there was no rheumatic diathesis 
either in the patients or in their parents. He also states that he has 
had under treatment many patients with gonorrhoea who were pre- 
disposed to rheumatism, and yet in them, urethritis has not been 
attended by any inflammation of the joints; and this fact derives 
additional weight from the frequency with which gonorrhceal 
rheumatism, after having once occurred, is re-excited by a subse- 
quent clap. These statements of M. Eollet go far to show that a 
rheumatic diathesis has no part in the production of gonorrhoeal 
rheumatism; it is desirable, however, that this point should be 
subjected to further observation. 1 

1 M. Rollet weakens his position by asserting an antagonism between a rheumatic 
diathesis and gonorrhoea, in virtue of which, he believes that a clap sometimes cures 
a patient of a tendency to rheumatism, from which he has previously suffered for 
years ! He says that he has observed one such case, and quotes another in detail 
which occurred in the practice of M. Diday ; but surely it is more reasonable to sup- 
pose that the disappearance of the rheumatism in these two cases was a mere coin- 
cidence. 

14 



210 GONORRHEAL RHEUMATISM. 

The exciting cause of gonorrhoeal rheumatism cannot be found in 
the use of copaiba and cubebs, as has been sometimes asserted, or in 
exposure to cold and sudden changes of temperature. Inflammation 
of the joints has frequently been known to occur in patients who 
have taken neither of these drugs, and who have been confined to 
the wards of a hospital during the whole course of their attack of 
gonorrhoea. On the other hand, how frequently are copaiba and 
cubebs administered for gonorrhoea, and how often must the subjects 
of clap be exposed to cold and moisture, and yet how rare is gonor- 
rhoeal rheumatism ! 

The phenomena of gonorrhceal rheumatism are also inconsistent 
with the idea of a metastasis from the urethra to the joints, since 
in most cases there is an exacerbation of the urethral discharge 
preceding the articular inflammation. This is especially noticeable 
in chronic cases of gleet, in which gonorrhceal rheumatism super- 
venes. 

The influence of sex in the production of gonorrhoeal rheumatism 
cannot be questioned. All the undoubted cases of this disease 
that have been published relate to men, and it must be extremely 
rare, if it exists at all, in women. 1 Eicord, Yidal, Cullerier, and 
a few other writers admit that it is occasionally met with in women, 
but have not reported their cases, if they have observed any. 

It will be seen from the above remarks how imperfect is our 
knowledge of the etiology of this disease, and it would be useless to 
enter into any farther speculations upon the subject. 2 

1 Foucart says : "I have not been able to find a single case of gonorrhoeal rheu- 
matism in the female, either in special treatises on this subject or in the medical 
journals." 

Brandes says : " The cases of gonorrhceal rheumatism in women reported by a few 
authors are far from conclusive. My own attention has been fixed on this point for 
six years, during which time I have not been able to find a single case at the only 
hospital in Copenhagen where venereal diseases in women are treated." 

Two very questionable cases are reported as occurring in the service of M. Rayer 
in 1846, the only account of which is as follows: "One woman was affected with^ 
inflammation of the elbow joint during the course of an attack of vaginitis. Another 
had nearly all the joints of the extremities slightly and successively inflamed, after 
several attacks of vaginal discharge." (Rollet. ) 

Another questionable case is related by MM. Blatin and Nivet(Trait6 des Maladies 
des Femmes). 

2 Rollet is inclined to believe that an explanation of the origin of gonorrhoeal 
rheumatism is to be sought for in the seat of gonorrhoea. He says: " There is no 
difficulty in admitting that when gonorrhoea extends to certain tissues or portions of 
the urethra, as yet undetermined, it may, in subjects constitutionally predisposed to 
this disease, excite inflanlmation of the joints." 



SEAT. 211 

Seat. — None of the joints are exempt from an attack of gonor- 
rhoea! rheumatism, but this disease affects the knee far more 
frequently than any other joint. The following table exhibits the 
order of frequency with which the various joints were affected in 
81 cases observed by MM. Foucart, Brandes, and Eollet : — 

Articulation of the knee ....... 64 

" " ankle 30 

" " hips .... 15 

" u fingers and toes . . . . . 15 

" " shoulder 10 

" " wrist 10 

" " elbow 8 

•* " sternum and clavicle .... 3 

** " tarsal bones 2 

" " sacrum and ilium 2 

" " lower jaw ...... 1 

" " tibia and fibula 1 

161 

Thus in 81 cases 161 joints were affected, and the knee was 
involved in 64. Besides the joints, gonorrhoeal rheumatism fre- 
quently affects the ocular tunics ; also the bursse connected with 
the muscular tendons, especially the tendo-Achillis ; and sometimes 
the sheaths of the muscles, as in muscular rheumatism. Again, 
Ricord states that he has met with several patients who suffered 
from severe pain in the plantar region, apparently seated in the 
fasciae. 

The knee-joint, therefore, is the favorite seat of gonorrhoeal 
rheumatism, though all the joints of the body are liable to its 
attacks. This disease, however, is less prone to change its seat from 
one joint to another than ordinary articular rheumatism. This fact 
is evident from an examination of the above table, which shows 
that there were but 161 joints affected in 81 cases; an average of 
about two joints to each case. I know of no similar table exhibiting 
the number of articulations affected in a given number of cases of 
ordinary rheumatism, but the proportion is undoubtedly much 
greater. Again, in 10 of the 19 cases in the above table, furnished 
by M. Foucart, only one joint was affected ; of the 34 cases of M. 
Brandes's, the rheumatism was mono-articular in 5, and also in 10 
of the 28 cases collected by M. Rollet. These facts, therefore, would 
give us a ratio of about one-third, in which gonorrhoeal rheumatism 
attacks but a single joint, but more extended statistics are required 
before this proportion is received as accurate. . 

Even when gonorrhoeal rheumatism does not remain confined to 



212 GOXOREHCEAL RHEUMATI3M. 

one joint, but extends to others, the articulation first affected docs 
not recover its normal condition, as it often does in ordinary articu- 
lar rheumatism, but generally continues in a state of inflammation 
after the disease is lighted up in other joints. In this respect, gonor- 
rhoea! rheumatism again differs from acute rheumatism, but approx- 
imates to the character of rheumatic gout. 

There can be no question, I think, that gonorrhceal rheumatism 
sometimes attacks the heart, but it is equally certain that this com- 
plication is much less frequently met with than in ordinary acute 
articular rheumatism. 1 Kicord states that in several clearly marked 
cases of gonorrhceal rheumatism, he has observed symptoms of en- 
docarditis, and also of effusion within the pericardium, but it is to be 
regretted that he has not given these cases in detail. The rarity of 
any mention of heart disease, however, in the reported cases of 
gonorrhoeal rheumatism, proves the correctness of the above asser- 
tion that this disease is usually free from such complication. The 
only undoubted case that I am acquainted with is one reported by 
Mr. Brandes : — 

A man, 50 years of age, had had five attacks of gonorrhoea within 
ten years; each attack being attended with disease of the joints. 
In a sixth attack he was seized with violent pain and swelling of 
several joints, especially the knee. A few days after, inflammation 
of the eye and pericardium ensued. The friction sound was well 
marked ; and the pulsations of the heart were irregular. There was 
dulness on percussion over a considerable space, with palpitation 
and pain in the precordial region. These symptoms improved under 
venesection and mercurials. Meanwhile the iris became inflamed in 
the right eye, and a week after this eye recovered, the left was 
attacked. The patient finally recovered, but suffered from weakness 
of the lower extremities for a long time, so that he was obliged to 
walk with crutches for several months. 

I have also received a verbal report of a similar case occurring 
in the practice of one of the most reliable surgeons of this city, but 
the details, drawn only from memory, are not sufficiently full to 
entitle them to publication. 

Kicord is the only authority, so far as I am aware, who has seen 
any affection of the nervous centres in gonorrhoeal rheumatism. 
This surgeon states that he has met with symptoms of compression 
of the spinal marrow and of the brain, such as paraplegia and 
hemiplegia, which appeared to be produced by increased effusion 

1 "I am induced to think that, under ordinary circumstances, some heart affection 
arises in about half of all cases of acute rheumatism." (Fuller on Jiheumatisn.) 



SYMPTOMS. 213 

within the serous membranes of the brain and spine, and which 
followed the same course as the affection of the joints. 

No affection of the lungs or pleura has ever been observed in 
gonorrhceal rheumatism. 

Gronorrhoeal rheumatism is essentially an hydrarthrosis, and in 
many instances the inflammation is confined to the synovial mem- 
brane of the joint during the whole course of the affection. The 
predilection of this disease for serous membranes is shown by its 
attacking the bur see connected with the tendons, especially about the 
wrist and ankle. Eollet states that he has seen one case in which the 
seat of the disease appeared to be a bursa accidentally developed 
over the acromion process, and Cullerier has met with the same in 
the bursa in front of the patella. 

Symptoms. — In describing the symptoms of gonorrhceal rheu- 
matism, it is desirable to take those of ordinary articular rheumatism 
as a standard of comparison. Proceeding in this manner, we find 
that gonorrhceal rheumatism is generally ushered in with less febrile 
disturbance than its more frequent congener. In some cases there 
is an entire absence of premonitory symptoms, and the patient's 
attention is not attracted to the joints until effusion has taken place 
and motion has thereby been rendered painful and difficult. In 
other instances, a slight chill and wandering pains have been ex- 
perienced, before the morbid action has become settled in any one 
joint; and those cases are exceptional in which the inflammatory 
symptoms at the outset are comparable in violence to those of acute 
rheumatism. 

When the articular disease is fairly established, the pain is in- 
creased and is often severe ; but here, also, we find the symptoms 
less acute, as a general rule, than in ordinary rheumatism. Even in 
those cases in which the local pain is great, there is much less general 
febrile excitement ; and an examination of the blood drawn in five 
cases by M. Eollet and in one by M. Foucart, failed to show that 
buffed and cupped condition of the clot which is so frequently met 
with in acute rheumatism. 

The integument covering the affected joint generally retains its 
normal color, though it sometimes puts on the blush of inflamma- 
tion. "When the knee-joint is the seat of the disease, as is frequently 
the case, the symptoms of a serous effusion within the capsule are 
readily detected. The patella is elevated above the femur and is 
treely movable ; the joint has the form of a cube, the usual depres- 
sion on either side of the patella being replaced by swellings, and 



214 GONORRHCEAL RHEUMATISM. 

fluctuation can be detected without difficulty. It is evident that 
the inflammatory process is confined to the synovial membrane, and 
that the fibrous and osseous tissues are unaffected. The collection 
of serum necessarily impairs the mobility of the joint, and pain is 
excited by pressure or by any attempt at motion. If the disease do 
not yield readily to treatment, other tissues about the joint become 
involved, and we may then find redness of the skin, together with 
fulness of the vessels and a corresponding increase of the pain and 
general febrile disturbance, assimilating the case to one of acute 
rheumatism. 

Those cases of gonorrhceal rheumatism which commence with the 
most decided inflammatory symptoms are generally the. most amena- 
ble to treatment ; those, on the contrary, in which the febrile action 
is but slight, and in which there is but little more than a passive 
effusion into the synovial sac, are more obstinate. 

Eecovery, in any case of this disease, can rarely be expected in 
less than a month or six weeks, and is often delayed for several' 
months or even years, especially when the patient is debilitated and 
when the affection of the urethra is allowed to run on, or does not 
yield to treatment. 

It is unnecessary to describe the symptoms of the cardiac affec- 
tion which sometimes complicates a case of gonorrhceal rheumatism, 
si-nce these do not differ from those of endocarditis and pericarditis 
attendant upon ordinary acute rheumatism. The inflammation of 
the eye which- frequently precedes or accompanies — or sometimes 
alternates with the disease of the joints, and which is evidently de- 
pendent upon the same condition of the general system, will presently 
receive special mention. . 

Most cases of gonorrhceal rheumatism terminate sooner or later 
in complete resolution, although they may render the patient a 
cripple for a long period. Suppuration within the bursa very rarely 
occurs. It is admitted by Ricord, who says, however, that it is 
always due to some accessory cause of inflammation; and Vidal 
mentions one case occurring under his charge in which it was neces- 
sary to open the joint and evacuate the purulent collection. An- 
chylosis, especially of the smaller joints, is a more frequent termi- 
nation of gonorrhceal rheumatism, and in scrofulous subjects, this 
disease has not unfrequently been followed by that strumous affection 
of the joints known as "white swelling;" here, as in other well-known 
instances, a constitutional cachexia selects the weakest part of the 
body as the seat of its manifestation. 



SYMPTOMS. 215 

Dr. Holsclier 1 reports a case in which death is said to have oc- 
curred from gonorrhoeal rheumatism. An abscess formed in the 
affected joint, and purulent infection ensued, terminating fatally. 

The period at which rheumatism makes its appearance in the 
course of a gonorrhoea appears to be more variable than that of 
epididymitis. Some cases are met with in which the affection of 
the joints occurs during the acute stage, or first week or two of the 
duration of the clap; and yet in. the majority of cases we find that 
the rheumatism manifests itself at a later period, when the urethral 
discharge has passed its climax. Generally, we find that the running 
has been more copious for a few days preceding the outbreak of the 
rheumatism, and this is especially noticeable in long-standing cases 
of clap which have been accompanied by several repetitions of the 
articular affection, each of which has followed an exacerbation of 
the discharge. Cases in which the running suddenly diminishes or 
entirely dries up before the rheumatism appears, must be regarded — 
in spite of the opposite opinion so frequently expressed — as rare and 
exceptional, and not sufficient for the basis of a theory of metastasis. 
In deciding this point — to which much importance has been at- 
tached — it should be recollected that if the rheumatism occurs 
several weeks after contagion, the discharge will probably have 
somewhat diminished, following the course which it usually pursues 
in cases entirely free from any complication. After the disease of 
the joints is established, the running sensibly decreases in most 
cases, as a consequence of revulsive action. In other instances — 
estimated by Rollet at about one-third — it remains without much 
change. It rarely disappears entirely, except as the result of 
treatment. • 

Gonorrhoeal rheumatism, unlike acute rheumatism, but like rheu- 
matic gout, frequently attacks the eye. 2 The ocular affection in these 
cases, is that form of "gonorrhoeal ophthalmia" which has been 
described by authors as " metastatic or sympathetic ; " but the differ- 
ence in the mode of origin, symptoms, prognosis, and treatment, 
between this form of ophthalmia and purulent conjunctivitis 
arising from contagion, is so great, that it would be desirable to 

1 Annales de Holscher, 1844. 

2 " In true rheumatism, the eye seldom suffers ; so seldom, that I find no record 
of any affection of that organ in more than 4 out of the 879 cases of acute and sub- 
acute rheumatism admitted into St. George's Hospital, during the time I held the 
office of Medical Registrar. But in rheumatic gout, the eye is not unfrequently 
implicated. It was inflamed in 11 out of the 130 cases of rheumatic gout admitted 
during the same period ; and it has suffered more or less severely in five out of 75 
cases, which have fallen under my own care at the hospital." (Fuller.) 



216 GONORRHCEAL RHEUMATISM. 

• 

distinguish, the two by different names, and to drop altogether the 
term gonorrhoea! ophthalmia, as applied to that ocular affection 
which accompanies gonorrhceal rheumatism. But before proceeding 
to further discussion of this point, it will be interesting and instruc- 
tive to compare the views of different authors relative to these two 
diseases. 

Mr. Tyrrell 1 denies the existence of gonorrhceal ophthalmia 
allied to purulent conjunctivitis and arising in any other way than 
by contagion, but he admits a conjunctivo-sclerotitis, due, as he 
supposes, to the metastasis of gonorrhoea. 

Mackenzie admits gonorrhceal conjunctivitis by contagion, by 
metastasis and by sympathy, and also a gonorrhceal iritis. 

Mr. Lawrence 2 admits three distinct forms of ophthalmic inflam- 
mation occurring in conjunction with, or depending on gonorrhoea, 
viz., 1st. Acute inflammation of the conjunctiva ; 2d. Mild inflam- 
mation of that membrane, ; and 3d. Inflammation of the sclerotic 
coat, sometimes extending to the iris. 

In speaking of the last - mentioned form, Mr. Lawrence says: 
" This affection of the eye is exactly the same as rheumatic inflam- 
mation of the sclerotic and iris, occurring independently of gonor- 
rhoea. Both this and the mild purulent inflammation of the 
conjunctiva are to be regarded as rheumatic affections of the organ 
excited by gonorrhoea ; that is, they take place in individuals, in 
whom this constitutional disposition is shown by inflammation 
affecting either -the synovial membranes, or the fibrous structures 
of the joints. Although the organs seem at first view very dissi- 
milar, there is an analogy of structure between the parts which 
suffer in thp two instances ; that is, between the synovial membranes 
and the conjunctiva, and between the ligaments and fibrous sheaths, 
and the sclerotica. Hence, we need not be surprised at finding that 
the eyes suffer under the influence of that unsound state of consti- 
tution which leads to these affections of the joints. The structure 
originally affected, the lining of the urethra, is also a mucous mem- 
brane, which sometimes becomes inflamed, and pours out a puri- 
form discharge, in gouty and rheumatic subjects from internal 
causes." 

Eicord admits two kinds of gonorrhceal ophthalmia ; one from 
contagion, the other metastatic or sympathetic ; but although he 
states that the latter may present all the symptoms of the former, 
yet his description of it differs widely from uncomplicated purulent 

1 Diseases of the Eye, vol. i., p. 387. 

2 On the Venereal Diseases of the Eye, London, 1830. 



SYMPTOMS. 217 

conjunctivitis. He says: "Not only the conjunctival, but also the 
sclerotic vessels are injected ; the eye appears more tense and more 
brilliant than natural ; the cornea often projects a little more than 
usual, and the iris is a little farther off; in some instances we may 
satisfy ourselves that the aqueous humor is increased. At times 
there are symptoms -of iritis, as a change of color in the iris, con- 
traction of the pupil, which is rarely distorted, and more or less 
photophobia. The aqueous humor may be cloudy, lactescent, or 
flaky, owing to inflammation of the membrane of Descemet, and 
false membranes may be formed, which give rise to adhesions, or 
pseudo-cataracts ; but pustules on the iris, or what have been called 
condylomata 'of the iris, are never seen as in syphilitic iritis. A 
process takes place in the eye analogous to what we meet with in 
the synovial membranes, in cases of gonorrhoeal arthritis, which, as 
I have already stated, sometimes accompanies this ophthalmia, or 
alternates with it. Sympathetic gonorrhoeal ophthalmia, other things 
being equal, is more irregular in its course, and more subject to 
relapses than the ophthalmia from contagion. It often changes its 
seat, which does not occur in the latter." It will be"" seen that this 
description covers the symptoms of inflammation of the deeper 
textures of the eye, especially the sclerotica and iris, rather than 
those of uncomplicated conjunctivitis ; and, in spite of Eicord's sub- 
sequent statement that the symptoms of the sympathetic disease may 
be identical with those of gonorrhoeal ophthalmia from contagion, 
it is evident that he is describing a different affection. 

Finally, M. Eollet 1 has taken the ground that sympathetic gonor- 
rhoeal ophthalmia is almost always an inflammation of the membrane 
of Descemet, and that it is invariably a manifestation of gonorrhoeal 
rheumatism. This surgeon calls attention to the fact so frequently 
noticed by others, that this form of ophthalmia is generally asso- 
ciated with gonorrhoeal rheumatism, but he is also inclined to believe 
that it may exist alone without any affection of the joints, and that 
as we often have one joint alone attacked by gonorrhoeal rheuma- 
tism, so the eye may be the only part of the body in which the 
rheumatic tendency shows itself. • 

With regard to the seat of this affection, M. Rollet does not deny 
that it may be in some other of the ocular tunics, but he maintains, 
that in the great majority of cases, it is in the iris. He goes farther, 
and asserts that it is the anterior layer of the iris which is attacked by 
the inflammatory process, which may extend to the posterior lamioa 

1 Op. cit. 



218 GOXORRHCEAL RHEUMATISM. 

of the cornea. According to this author, therefore, this affection is 
an aquo-capsulitis, or, more properly speaking, a kerato- iritis, the 
symptoms of which are the following : injection of the conjunctival 
vessels and especially of the zone of sclerotic vessels around the 
cornea ; occasional photophobia and increase in the flow of tears ; a 
nebulous appearance of the cornea; an increase of the aqueous 
humor ; dulness of the iris, and a deposit of plastic material in the 
anterior chamber (which Mackenzie states is unequalled in degree 
in any other form of iritis), occasioning great obscuration of vision. 
Generally both* eyes are attacked simultaneously or consecutively. 
The disease may terminate in resolution, or atresia iridis. It differs 
from syphilitic iritis, in that the latter affects the substance of the 
iris, produces a greater change in its color, often gives rise to tuber- 
cular excrescences, deforms the pupil to a greater extent, and is 
more likely to cause adhesions between the iris and anterior capsule 
of the lens. In the opinion of M. Eollet, the symptoms of gonor- 
rhoea! iritis now described are so constant, and so different from the 
effects of common rheumatism upon the eye, that he regards this 
affection as one proof that gonorrhoeal rheumatism is a distinct 
species apart from rheumatism produced by other causes. 

It thus appears that several authors have recognized the fact that 
•' sympathetic gonorrhoeal ophthalmia" is dependent upon the same 
condition of the general system as gonorrhoeal rheumatism. More- 
over, in all the cases which I have been able to find recorded, these 
two diseases have coexisted within a short space of time ; the affec- 
tion of the eye, in all of them, has been either preceded, attended, 
or followed by rheumatism, and in some instances they have alter- 
nated with each other. 

Again, the tissues of the eye affected are the same as those usually 
involved in rheumatic gout, with which gonorrhoeal rheumatism has 
so many other points of resemblance. These considerations are 
sufficient, I think, to establish the identity of the two diseases, and 
to authorize the conclusion that the affection of the eye is but one 
manifestation of gonorrhoeal rheumatism. It is no objection to this 
view that the ophthalmia sometimes precedes the affection of the 
joints, for the same is true of inflammation of the heart attendant 
upon acute rheumatism, 1 and we may also admit, that in some cases, 

1 " In summing up the principal facts deserving of notice in reference to rheumatic 
inflammation of the heart, I should say that it is incidental to all the stages of acute 
rheumatism, occurring sometimes before the commencement of inflammation of the 
joints, and possibly, also, in some rare instances, without the concurrence from 
first to last, of any active articular symptoms." (Fuller on Rheumatism, Am. ed., 
N. Y., 1854, p. 165.) 



SYMPTOMS. 219 

though I have not met with any such, the disease of the eye is the 
only evidence of a rheumatic tendency, the joints remaining entirely 
unaffected. 

The present classification of this form of ophthalmia, does away 
with many difficulties which have heretofore surrounded this sub- 
ject, and reconciles many discrepancies to be found in books. The 
"mild gonorrhoeal conjunctivitis" of Lawrence, the "gonorrheal 
conjunctivo-sclerotitis" of Tyrrell, and the "gonorrhoeal iritis" of 
Mackenzie and others, are seen to be essentially the same disease, 
dependent upon a rheumatic tendency induced by gonorrhoea, and 
capable of manifesting itself in any of the external tunics of the 
eye. The difficulty of admitting a disease of the eye originating 
in gonorrhoea, otherwise than by contagion, is done away with ; it is 
no longer necessary to call in question the cleanliness of patients, 
or to suspect constitutional syphilis in the entire absence of proof 
that such exists; and the obscure phenomena of metastatic and 
sympathetic gonorrhoeal ophthalmia are found to be in accordance 
with the laws which govern ordinary rheumatic ophthalmia. 

In the following table of cases of gonorrhoeal rheumatic ophthal- 
mia, I have included all the more noted facts which from time to 
time have been published by some of the most eminent authorities 
in our profession. Most of them have been related by their authors 
as instances of " metastatic or sympathetic gonorrhoeal conjunctivitis, 
iritis," etc. In many cases, the details are very imperfect, and it is 
very probable that in some the disease of the' eye was merely 
catarrhal ophthalmia coexisting with gonorrhoea, but I have thought 
it best to make no attempt to sift them, the better to enable the 
reader to form his own conclusions on the facts at present in our 
possession. This table includes nearly all the cases which I have 
been able to find in a somewhat extended search through works on 
Venereal, and Diseases of the Eye. 



220 



GONORRHEAL RHEUMATISM. 



REPORTED CASES OF « METASTATIC GONORRHEAL OPHTHALMIA' 

SO-CALLED. 



llBrodie's Se- 
lect Surgical 
Works ; Dis- 
eases of the 
Joints; Phil., 
1847, p. 35. 



Ibid., p. 36. 



Ibid., p. 37. 



Ibid., p. 37. 



Ibid., p. 38. 



Lawrence on 

the Venereal 

Diseases of 

the Eye; 

London, 

1830, p. 104. 

Ibid., p. 107. 



Ibid., p. 111. 



Ibid., p. 114. 



Patient 45. 
years of age. 



Case obscure- 
ly reported. 



Patient with 

strictures of 

urethra. 



Patient aetat. 
23. 



John Harley, 

aged 38, had 

never had 

rheumatism 

before. 



Gentleman, 

52 years of 

age. 



Mr. G., actat. 

33, of good 
constitution ; 

had never 
suffered from 

rheumatism. 



Mr. C, aetat. 
38; full liver 
and subject to 
rheumatism. 



Four 
at- 
tacks. 



Nine. 



Two. 



Four. 



One. 



One. 



Seve- 
ral. 



One. 



Contracted gonorrhoea in the middle of June, 1817. 
Rheumatism of foot commenced June 23 ; ophthal- 
mia June 24 ; conjunctivae much inflamed with pro- 
fuse discharge of pus. Complete recovery. 

2d attack in Dec. 1817, similar to preceding, but leaving 
him crippled. 

3d and 4th attacks in March, 1818 and 1822, in which 
the inflammation was situated in the " proper tunics" 
of the eye (sclerotica, iris, and choroid). 

In four attacks, purulent ophthalmia ; in two, inflam- 
mation of the sclerotica and iris; inflammation of 
various joints and bursae mucosae. 

Gonorrhoea in 1809, with swelled testicle, purulent oph- 
thalmia, and inflammation of synovial membranes. 
Similar attack in 1814, except no swelling of testicle. 

In all, the urethritis was the first symptom, and was 
followed by purulent ophthalmia and inflammation 
of synovial membranes. In two of these cases, the 
gonorrhoea was attributed to contagion, and in the 
two others to the use of bougies. 

Purulent discharge from the urethra; inflammation of 
knee-joint with effusion; slight inflammation of the 
conjunctiva, which subsided under the use of reme- 
dies directed to the rheumatism. 

One month after appearance of gonorrhoea, was attacked 
with " acute external inflammation " of both eyes, 
resulting in extensive ulceration of corneae and im- 
paired vision; within one week after commencement 
of ophthalmia, had rheumatism of several joints. 



Slight discharge from the urethra in 1822, which the 
patient did not attribute to infection, followed by in- 
flammation of conjunctiva, chemosis, and puriform 
discharge. The eye symptoms disappeared, when 
rheumatism of one knee and both hands set in ; as 
the latter grew better, the eyes became inflamed 
again. This attack lasted for two years. 

The patient was seen again in 1828. No recurrence of 
acute rheumatism, though the joints were still stiff 
from old attack. Had had at least six attacks of in- 
flammation of the eyes since former visit, and the 
contraction of pupils and adhesions to capsule showed 
that the iris had been involved. No return of urethral 
discharge. 

Urethral discharge appeared July 9th, 1827; eyes be- 
came inflamed July 23d; symptoms those of simple 
acute conjunctivitis, without chemosis or profuse 
purulent discharge. Severe pain in the hip and 
thigh came on July 24th. Patient improved and 
was supposed to be well, but had a short relapse of 
urethral discharge, ophthalmia, and pain in hip, 
after exposure, Aug. 9th. 

Gonorrhoea followed by inflammation, with effusion of 
knee and swelling of hands. Symptoms were im- 
proving and urethral discharge had ceased, when 
mild inflammation of the conjunctiva came on in 
both eyes ; this subsided in a few days under the use 
of tepid lotions. 



AFFECTION OF THE EYES. 



221 



10 



Ibid., p. 115. 



11 



Ibid., p. 118. 



12 



Ibid., p. 120. 



13 



14 



15 



Ibid., p. 123. 



Ibid., p. 124. 



Ibid., p. 127. 



16 



Tyrrell, v >1. 
i., p. 387 



Mr. C, astat. 
30, of spare 
habit and 
leading a se- 
dentary life. 



Patient of 
spare habit 
and good con 
stitution ; had 
always en- 
joyed good 
health ; age 
28. 

Patient 24 

years of age, 

and good 

constitution. 



Patient 
aged 25. 



Mr. F., 29 
years of age. 



Mr. L., 29 
years of age. 



Patient 46 
years of age. 



One. 



Two. 



One. 



One. 



Four. 



Within a few years after marriage, had four attacks of 
discharge from the urethra, "without infection." 
The last of the four attacks was attended with pain- 
ful swelling of the foot and enlargement of the 
glands in the groin. Four years afterwards (June, 
1827) had an acute attack of aquo-capsulitis in left 
eye, with copious effusion of lymph in anterior cham- 
ber; under treatment these symptoms entirely disap- 
peared. 

Sept. 7th, contracted gonorrhoea from impure connec- 
tion. Sept. 18th, mild conjunctivitis ensued in both 
eyes ; and, Sept. 21st, rheumatism of foot and upper 
extremities, the discharge from the urethra still con- 
tinuing. 

In Feb. 1828, he had severe inflammation of the exter- 
nal tunics and iris on both sides; some stiffness of 
joints still remained ; no mention of the urethral dis- 
charge. 

An attack of gonorrhoea was getting better, when 
rheumatism of the joints of foot and of the knee 
appeared, followed in a short time by inflammation 
of the sclerotica and iris in both eyes, which left 
permanent adhesions between the iris and anterior 
capsule. 



1st attack. Patient contracted gonorrhoea, the symp- 
toms of which were very severe. In three weeks, 
both eyes became "red and inflamed, painful and 
acutely sensible to light; lachrymation and mucous 
discharge" (inflammation of the sclerotica and iris). 
No affection of joints mentioned. 

2d attack, occurring 18 months after the preceding. 
As before, a severe attack of gonorrhoea followed in 
a fortnight by an attack of conjunctivitis, which dis- 
appeared in a few days. About a fortnight after, 
however, the gonorrhoea still continuing, the eyes 
again became inflamed; the inflammation being 
seated in the " deeper tunics." Soon after rheuma- 
tism appeared affecting all the joints of the body, 
but particularly the knee. 

Patient continued well for about two years, when he had 
a severe attack of rheumatism without any affection 
of the eyes. 

Patient had had a slight gonorrhceal discharge for 
some time, when inflammation of the internal tunics 
and iris of both eyes ensued, followed in a few days 
by inflammation of the knee-joint. The eyes re- 
covered in a month, the urethritis and rheumatism 
still continued for a year afterwards. 

Five weeks after the commencement of an attack of 
gonorrhoea, had severe pains in the back, sides, and 
lower limbs ; after these had continued a fortnight, 
he had injection of the sclerotic vessels, with pro- 
fuse lachrymation and dimness of vision. 

Had an attack of gonorrhoea nine years ago, unac- 
companied by any rheumatic affection. Four years 
ago, had gonorrhoea, followed by rheumatism, which 
affected particularly the feet. 

A third attack of gonorrhoea, ten months ago, followed 
in a week by rheumatism in the feet, which has con- 
tinued till the present time; meanwhile he has had 
an attack of sclero-iritis in each eye. 

Gonorrhoea; inflammation of several joints with effu- 
sion ; inflammation of conjunctiva and sclerotica in 
both eyes, and in one extending to the iris and cho- 
roid. Order of sequence of these affections not given. 
Other three attacks similar. 



222 



GONORRHEAL RHEUMATISM. 



Ibid., p. 392. 



Ibid., p. 394. 
Ibid., p. 394. 

Ibid., p. 395. 



Vetch, Prac- 
tical Treatise 
on the Dis- 
eases of the 
Eye; London, 
1820, p. 243. 



22 1 Prof. Graves, 
London Med. 

Gaz., new 

series, vol. i., 

p. 440. 



Sir Astley 
Cooper, Lec- 
tures on the 

Principles 
and Practice 
of Surgery ; 

London, 
1835, p. 482. 



Rollet, An- 
nuaire de la 

Syphilis ; 

annee 1858, 

p. 19. 



Ibid., p. 20. 



Brandes, 
Arch. Gen. 

de Med., 
Sept. 1854. 



Patient 20 
years of age, 

fair com- 
plexion and 
scrofulous 
diathesis. 



Patient 25 
years of age, 



P., aged 35 
years. 



Patient aged 

24 years, an 

inmate of the 

Venereal 

Hospital at 

Lyon. 

Patient aged 

30 ; never had 

rheumatism 

before. 



One. 



One. 
One. 



Six or 
seven. 



Two, 
at five 
years' 
inter- 
val. 



Four. 



Three. 



One. 



One. 



Two 
at an 
inter- 
val of 
three 
years. 



After the acute stage of an attack of gonorrhoea had 
subsided, inflammation of the synovial capsule of 
the knee and of the conjunctiva and sclerotica of 
both eyes. 



" Similar to the last case." 

Similar to the two previous cases, except that the in- 
flammation extended to the iris and choroid of one 
eye. 

Each attack was preceded by slight gonorrhoea; no 
inflammation of synovial membranes, but rheumatic 
pains about shoulders, arms and neck prior to dis- 
ease of eyes ; inflammation of conjunctiva and scle- 
rotica, dull aching pain in globe and brow aggra- 
vated at night, dull condition of iris, irregular pupil, 
muscae. 

In each attack the subsidence of the gonorrhoea was 
attended by rheumatism of the knee and joints of 
foot, followed by inflammation of the sclerotica and 
iris ; irregular and contracted pupil, synechia, opacity 
of capsule of lens, and impaired vision. There was 
no chemois or purulent discharge in either attack. 
Swelled testicle present in the first. 

The gonorrhoea in each attack ran its course till the 
discharge and inflammation began to decline, when 
the eyes invariably became inflamed, presenting all 
the symptoms of simple acute conjunctivitis, and 
after a few days the sclerotica and other tissues be- 
came involved. Again, after the ophthalmia had 
lasted a few days, one of his joints invariably was 
affected with acute inflammation. 

An American gentleman applied to Sir Astley Cooper 
to be treated for gonorrhoea, and told him that in 
two former attacks he had had inflammation in the 
eyes, and rheumatism in the joints. Sir Astley cau- 
tioned him against allowing any matter from the 
urethra to come in contact with the eye. Three days 
after, the man had "ophthalmia" in both eyes, which 
was cured with great difficulty; and in three days 
more he had rheumatism in each knee. (It is evi- 
dent that the disease of the eye in this case was not 
purulent conjunctivitis.) 

Inflammation of eyes commenced eight clays after 
gonorrhoea; redness of conjunctivas, lachrymation, 
cornea slightly opaque, atresia and irregularity of 
pupils, circumorbital pains. Inflammation of knee- 
joint with effusion took place four days after the dis- 
ease of eyes appeared. 

Disease of the eye appeared eight days after urethral 
discharge. Left eye only affected; injection of con- 
junctival vessels ; pupil irregular, iris darker than on 
opposite side; slight opacity within the pupil; pain 
in the orbital region. Inflammation of joints of knee 
and foot came on in about seven weeks, the disease 
of urethra and eye still continuing. 

■ 

1st attack. The day following the appearance of a 
gonorrhoea, patient began to suffer from an "oph- 
thalmia" of both eyes nnd pain in one shoulder. 
The ophthalmia subsided under treatment. A re- 
lapse taking plaoe, several joints were affected with 
rheumatism, the iris became inflamed, with hypopion. 



AFFECTION OF THE EYES. 



223 



27 



Same 

author 



Patient had 
stricture, and 
these several 

attacks were 
probably not 

due to fresh 
contagion. 



2d attack. Ophthalmia appeared in five days, and * 
rheumatism in eight, after gonorrhoea ; iris inflamed, 
several joints involved. 

Five at I Inflammation of the iris, followed by rheumatism, in 



inter 
vals of 
one or 

two 
years. 



each attack. 



In all the cases included in this table, the eye disease was preceded, 
attended, or followed by rheumatism. In a majority of the attacks 
the ophthalmia preceded the rheumatism. 

In about two-thirds of the cases of which we have sufficient details 
to enable us to determine the seat of the ophthalmia, the sclerotica 
and iris were chiefly affected; in the remaining third, the conjunctiva. 
In the latter class, it is sometimes noted that there was purulent 
discharge and chemosis ; but the inflammation does not appear to 
have assumed the severity of gonorrhoeal ophthalmia from contagion, 
since only one (No. 6) terminated in ulceration of the cornea, and 
most of the cases yielded readily to treatment. 

We may conclude, therefore, that gonorrhceal rheumatism, like 
rheumatic gout, may attack any of the ocular tunics, though it most 
frequently involves the sclerotica, from which it may extend to the 
conjunctiva, iris, or other tissues. 1 It must be borne in mind that 
the vascular connection of all the tissues of the eye is very intimate, 
and that the inflammatory process is never wholly confined to one 
portion of the globe. It is highly probable, I think, that many 
cases of gonorrhoeal rheumatic ophthalmia, which have been de- 
scribed as conjunctivitis, have in reality been instances of conjunc- 
tivo-sclerotitis, in which the injection of the conjunctival vessels has 
masked that of the sclerotica. The orbital and circumorbital pain, 
which are often mentioned, would indicate this. At the same time, 
it must be confessed, that in some instances the chief seat of the 
disease has been the conjunctiva, and that the presence of a muco- 
purulent discharge and a certain degree of chemosis, have rendered 
these cases readily mistakable for gonorrhoeal ophthalmia from con- 
tagion. The milder character of the disease, the history and habits 
of the patient, and the existence of rheumatism, are, in such instances, 
the chief elements on which to found a diagnosis. When a patient 
has had an affection of the eyes and joints in previous attacks of 
gonorrhoea, or when gonorrhceal rheumatism coexists with an oph- 



1 These cases do not confirm Rollet's statement, that gonorrhoeal rheumatic oph 
thalmia is always a kerato-iritis. 



224 GONORRHEAL RHEUMATISM. 

» thalmia which does not present the severe symptoms of purulent 
conjunctivitis, there is a strong probability that it is of the rheu- 
matic form, even though the conjunctiva appears to be chiefly affected. 
Not unfrequently, also, rheumatic ophthalmia, after entirely disap- 
pearing from one eye, involves the opposite eye, or returns a second 
time to the one first affected, a course never pursued by gonorrhceal 
ophthalmia from contagion. 

In by far the larger proportion of cases,. however, as shown by 
the above table, the symptoms of gonorrhceal rheumatic ophthalmia 
are those of sclerotitis, iritis, or kerato-iritis, either separate or com- 
bined. I shall not attempt to describe the characteristic features of 
these different forms, since they are identical with those of the same 
iffections arising from other causes. 

I will merely remark that when the iris is involved, it generally 
appears to be so secondarily, and that the inflammation affects it to 
a less extent and more superficially than in other forms of iritis ; 
hence that there is less danger of adhesions to the capsule of the 
lens and of atresia iridis, and that tubercular excrescences are pro- 
bably never seen upon its surface. 

Diagnosis. — The admission of gonorrhoeal rheumatism as a dis 
tinct disease, is by no means dependent upon the question whethei 
it presents any symptoms different from those of ordinary rheuma- 
tism. Inflammation of the epididymis, identical with swelling of 
the testicle attendant upon gonorrhoea, may be excited by other 
causes ; and even if no diagnostic signs of the rheumatism caused 
by urethritis be admitted, we should still be warranted in using the 
term " gonorrhoeal rheumatism" as indicating the connection between 
the two diseases. 

It is evident, however, that the disease now under consideration 
differs in some respects both from acute rheumatism and rheumatic 
gout, though much more closely allied to the latter than to the 
former. 

It differs from acute rheumatism in the absence or slightly marked 
character of its premonitory symptoms ; in the less degree of consti- 
tutional disturbance which attends it; in being limited to a few 
joints; in its predilection for the synovial membranes; in rarely 
attacking the heart, but frequently the eye ; in its persistency ; and 
in seldom affecting women. It differs from rheumatic gout in the 
fact that hereditary influences, so far as at present proved, have no 
part in its production ; also in the frequency with which it attacks 



NATURE. 225 

the kneerjoint ; in its preference for the male sex, and in its rarely 
leaving any permanent traces of its invasion. 

Whether these points of difference are sufficient or not to consti- 
tute a distinct species of rheumatism, is a question which probably 
cannot be decided with satisfaction to every mind. Even the laws of 
classification in the animal and vegetable kingdoms are as yet far 
from being settled ; much less can it be said that there are fixed 
rules for determining how great a degree of difference will justify a 
distinct species in the natural history of disease. All that we' can 
say with regard to gonorrhceal rheumatism, is, that in well-marked 
cases, it presents certain characteristic features sufficient to indicate 
its origin, even when before unknown. In some instances, its symp- 
toms resemble those of other forms of rheumatism so closely that 
we should not be led to suspect its character, unless aware that the 
patient was suffering from gonorrhoea. 

In a given case of this kind, therefore, it may at times be 
extremely difficult to determine whether our patient has an affection 
of the joints dependent upon his urethritis, or whether his rheu- 
matism is simply a coincidence ; if, however, there be but little 
constitutional disturbance ; if only a few joints, and particularly the 
knee, be affected ; if the disease be chiefly confined to the synovial 
membrane — as shown by the articular effusion, and the slight degree 
of heat and redness externally — and if it exhibit but slight tendency 
to migrate from one joint to another, then there can be little question 
that the gonorrhoea and rheumatism bear to each other the relation 
of cause and effect. The probability will be still further strength- 
ened, if the patient has never been subject to rheumatism ; or, a 
fortiori, if he has had it only in conjunction with previous attacks 
of gonorrhoea. 

Nature. — The power of exciting rheumatism, exercised by gon- 
orrhoea in certain cases, has often been advanced as an argument to 
prove that the latter disease is a modified form of syphilis ; and it 
has been asserted that the rheumatism is due to the absorption of a 
specific poison from the urethra. This idea has probably derived 
additional weight from the supposition that no other satisfactory 
explanation could be given of the connection between these two 
diseases, and before such was found, the theory of a syphilitic or 
gonorrhceal virus was thought to be the only alternative. The 
question has been asked : If the rheumatism is not produced by the 
absorption of a specific poison, how is it produced? But such a 
process of reasoning is founded on a gross over-estimate of our know 

15 



226 GONORRHEAL RHEUMATISM. 

ledge of cause and effect in disease. The connection between gon- 
orrhoea and rheumatism is only one of many instances, in which the 
link which binds two diseases together escapes us, although the 
union is plain and unquestionable. Who, for instance, can account 
for the intermittent fever which is sometimes occasioned by a 
stricture of the urethra ; or explain the connection between chorea 
and rheumatism — a connection so intimate that a large proportion 
of children who have the one will have the other ; or the reason 
that' disease of the supra-renal capsules causes bronzing of the skin? 
And so throughout the etiology of all diseases, if for a moment we 
endeavor to divest our minds of the familiarity which daily obser- 
vation has given to the connection between them and the causes 
which produce them, in how few instances do we really understand 
the mechanism of the process! 

Facts which occur but rarely, excite wonder; if frequent or 
coinciding with other known phenomena, the mind receives them 
without distrust. Is it then an isolated fact that a local affection, 
entirely destitute of specific properties, is capable of exciting rheu- 
matism ? By no means. Dr. Fuller, who believes that the proximate 
cause of rheumatism is a poison generated in the system (not 
absorbed from without) as the result of faulty metamorphic action, 
thus speaks of the influence of local disease: "One part of the 
animal economy hinges so closely on the other, that local mischief 
occasions general disturbance, and under certain circumstances 
appears to induce a state of system favorable to the generation of 
rheumatic poison; a state of system arising, be it observed, not 
as a direct and immediate consequence of suspended secretion, but 
as a sequel of perverted function gradually taken on by the system 
generally, in consequence of imperfect or morbid local action. 
Excessive venery and long-continued debauchery are frequently 
productive of rheumatism, and so is immoderately protracted lac- 
tation. The phenomena of gonorrhoea afford an admirable example 
of how local diseases gradually give rise to general derangement 
of the system, and so to the production of the peccant matter 
of rheumatism." 1 This connection between local diseases in 
general and inflammation of the joints is also fully recognized by 
other observers ; it need not therefore surprise us, nor is there any 
necessity to suppose the absorption of a specific poison, when we find 
that rheumatism can be excited by inflammation of the urethra. 

Moreover, evidence is not wanting to show that the phenomena 

1 Fuller on Rheumatism, p. 35. 



TREATMENT. 227 

of gonorrhoeal rheumatism cannot be explained on the ground that 
the syphilitic or any other specific poison has been taken into the 
system from without. In order not to extend this subject to too 
great length, I will merely enumerate the chief points of this 
evidence. 

1. If. gonorrhceal rheumatism were due to the absorption of a 
virus, it ought to be a very frequent disease, considering the multi- 
tude of patients affected with gonorrhoea; it is, however, quite 
infrequent. 

2. On the same supposition, it ought to run a regular and definite 
course, like specific diseases in general. 

3. One attack, also, should afford immunity from, or at least par- 
tial protection against subsequent attacks in the same person. 

4. No evidence of the absorption of a virus is found in an ex- 
amination of the lymphatic vessels or ganglia in gonorrhoea, as in 
syphilis. Even in cases of gonorrhceal rheumatism, the absorbents 
in the neighborhood of the genital organs retain their normal con- 
dition. 

5. Gonorrhceal rheumatism has repeatedly been known to occui 
in connection with urethritis which had been excited by the use of 
bougies, or by intercourse with women during the menstrual period 
If it can thus be caused by a simple urethritis, why is it ever neces- 
sary to attribute it to a "virulent gonorrhoea?" 

6. None of the known symptoms of syphilis bear any more than 
the slightest resemblance to gonorrhceal rheumatism. 

Treatment. — It is evident that we cannot deduce the treatment 
of gonorrhceal rheumatism from that of acute rheumatism, as has 
sometimes been done by writers on this subject ; nor, again, entirely 
from that of rheumatic gout, although here, it is not improbable 
that a somewhat similar line of treatment may be found applicable. 
But if we recognize a special cause and certain peculiarities in the 
symptoms of gonorrhceal rheumatism, the treatment of this disease 
demands investigation independent of any preconceived notions 
derived from our experience with kindred affections. 

The amount of constitutional disturbance attending the commence- 
ment of an attack of gonorrhceal rheumatism is rarely sufficient to 
require active antiphlogistic measures. The administration of an 
emetic, or a free purge, as from five to ten grains of calomel, fol 
lowed by castor oil or Epsom salts, is commonly sufficient to allay 
the febrile excitement, and has the additional advantage of correct- 
ing the condition of the digestive organs which are usually at fault. 



228 GONORRHEAL RHEUMATISM. 

The patient should be kept quiet, and his diet be proportioned to 
the severity of the febrile action. The chief means of combating 
the local inflammation is to be found in the abstraction of blood 
from the neighborhood of the joint. Cups or leeches should be 
applied, and repeated as often as the case requires. They afford 
marked relief to the pain, often arrest the progress of the disease, 
and hasten its resolution. 

After the more acute symptoms have been subdued, or even at 
the outset, when the disease is from the first of a subacute character, 
the greatest benefit will be derived from blisters. These are espe- 
cially applicable, when a large joint, like the knee, is attacked, and 
when an effusion within the capsule is a prominent symptom. The 
vesicated surface may be dressed with simple cerate with the addi- 
tion of five grains of morphine to each ounce, and so soon as the 
surface heals a fresh blister may be applied. If strangury ensue, 
the daily application of strong tincture of iodine may be substituted 
for the unguentum lyttse. Velpeau recommends that the joint be 
kept constantly smeared with mercurial ointment, to which some 
preparation of opium has been added. 

Ricord and some other writers advise the internal administration 
of colchicum, alkalies, and the salts of potash, as in rheumatism 
dependent upon other causes, but the reports of cases in which these 
remedies have been employed are far from proving their efficacy. 
The occasional use of an emetic or purge has in the hands of several 
surgeons been found to be of decided advantage. Eollet speaks 
highly of vapor baths. Copaiba and cubebs have no effect upon the 
•rheumatism, and can only be required for the urethritis, which, in 
most cases, however, is more satisfactorily treated by local measures. 

Meanwhile, the treatment of the urethral discharge on which the 
rheumatism depends, should not be neglected. Unless this be en- 
tirely arrested, there is always danger of a relapse. In many of the 
cases reported, the rheumatism has repeatedly returned at intervals 
of several months, so long as the exciting cause continued. The 
measures already recommended for the treatment of gonorrhoea and 
gleet should, therefore, be actively employed, at the same time that 
attention is paid to the affection of the joints. 

When gonorrhoeal rheumatism occurs in persons of broken-down 
constitution, or when the general health becomes impaired by the 
continuance of the urethral and articular disease, it is necessary to 
resort to hygienic measures, and frequently to the administration of 
tonics, as preparations of iron, iodine, cod-liver oil, bark, etc. These 
remedies, together with fresh air and good diet, should by no means 



TREATMENT. 229 

be neglected, as soon as the patient is found to be debilitated. Bar- 
well believes that gonorrhoeal rheumatism depends upon slight 
purulent infection, and recommends large doses of quinine. 

A very efficacious method of treating the swelling which often 
remains after the acute symptoms have subsided, is by means of 
strips of adhesive plaster so applied as to exercise compression and 
at the same time render the joint immovable. Supposing the knee 
to be affected, the limb should be bandaged from the toes up to the 
point where the plaster is to commence, or just- below the swelling. 
The strips should be of about two fingers' breadth, and each one, 
first passed behind the limb, be brought round in front, and its ends 
made to cross like the letter X. One strip after another is applied, 
each overlapping the preceding for about one-third its width, until 
the whole joint is covered, when four or five additional layers are 
superposed in the same manner, in order to insure a sufficient degree 
of stiffness, and the whole enveloped in a bandage. I can speak 
very decidedly of the good effects of this application in this and 
other chronic affections of the joints. 

When the eye becomes inflamed, local depletion by means of 
leeches or cups to the temples should be resorted to. If the con- 
junctiva be involved, the strictest cleanliness should be maintained 
by frequent bathing with tepid water. Astringent collyria are less 
frequently called for than in conjunctivitis independent of any rheu • 
matic taint ; if used, their effect should be carefully watched, and, 
if they fail to afford relief, they should be omitted. When the iris 
is implicated, the pupil must be dilated by atropine, and mercurials 
administered as in other forms of iritis. 



230 VEGETATIONS. 



CHAPTER XII. 

VEGETATIONS. 

Vegetations are papillary growths springing from the skin or 
mucous membrane chiefly in the neighborhood of the genital organs, 
and identical in their nature with the warts which are so common 
upon the hands. They are not, strictly speaking, venereal, since 
they are not necessarily connected with either of the diseases origi- 
nating in sexual intercourse. It is true that they are most frequently 
observed in men and women who have been affected with gonor- 
rhoea, balanitis, chancroids, or syphilis ; but this is simply because 
the skin or mucous membrane has for a time been moistened with 
an acrid secretion which has favored the abnormal development of 
its papillae. They are found in young children, with regard to 
whose purity there can be no suspicion ; and also in adults who 
have never suffered from any venereal disease whatsoever. Again, 
they are not unfrequently met with during pregnancy ; the increased 
secretion from the vagina and the determination of the blood to the 
pelvis at this time being highly favorable to their development. 

The importance of these growths has been very much exagger- 
ated. Thus, they have been regarded as syphilitic, and as an indica- 
tion of the necessity of specific remedies ; and this, too, in spite of 
the generally recognized fact that mercury has no effect whatever in 
their removal. Their only connection with syphilis is when they 
spring from the surface of a chancre, mucous patch, or other general 
lesion, upon which they are a merely accidental formation. The 
sore which serves as their base may require a mercurial course, but 
the superadded vegetation in itself presents no such indication. 

Again, it is often said that they are contagious ; and some sem- 
blance of truth for this supposition has been found in the fact that 
when situated upon one of two opposed surfaces, as the labia or 
upper and inner parts of the thighs, similar growths not unfrequently 
spring up upon the opposite; and somewhat doubtful cases have 
been reported in which, as alleged, vegetations have appeared upon 
men after connection with women who were similarly affected. But, 



VEGETATIONS. 231 

such instances are readily explained on the ground that the acrid 
secretion from vegetations, when applied to neighboring parts, and 
possibly, when transferred to another individual, acts in the manner 
already explained, and gives rise to others. The very fact that their 
supposed contagion takes place upon the person affected, is sufficient 
to prOve that they are not dependent upon the virus of true syphilis, 
the lesions of which are not auto-inoculable ; and there is no reason 
whatever for ascribing them to the poison of the chancroid. More- 
over, they present the same aspect, follow the same course, and are 
amenable to the same treatment, when occurring in young children 
and pregnant women who are otherwise healthy, as in persons affected 
with venereal diseases. 

Several varieties of vegetations have been admitted, especially by 
the French, founded upon their resemblance to various objects in 
nature. Thus, Alibert, who believed that vegetations were syphi- 
litic, admitted them as one of three principal forms of the syphilo- 
dermata ; and divided them into six varieties : " La syphilis vegetante 
framboisee;" "en choux fleurs ;" "encretes;" "en poireaux;" and 
" en vermes ;" to which he added the truly syphilitic lesion, mucous 
patches, under the head of " condylomes." 

No useful purpose, however, is attained by this classification, 
which serves only to confuse the mind ; since the form of vegetations 
is solely dependent upon accidental circumstances, as their position 
and the pressure of neighboring parts. It is sufficient to know that 
they are sometimes flat and but little elevated above the surface ; 
while at others they are attached by means of a pedicle of variable 
diameter ; and that they are chiefly developed in whatever direction 
they meet with the least resistance. When exposed to the air they 
are often dry and hard ; when protected by an opposed surface, they 
are soft and smeared with a highly offensive secretion. 

Their microscopical appearances are thus described by Lebert: 
" A feeble power shows their internal vascular structure and numer- 
ous sebaceous follicles about their base. With a high power, the 
papillae appear to be composed of an outer rind consisting of con- 
centric layers, and of an internal substance ; the two differ from 
each other only in density ; for, besides their vascular element, they 
consist only of epidermic cells. In the outer layers, these cells are 
more densely packed and present a longer and narrower outline, 
which, at first sight, gives them a fibrous appearance. The internal 
portion is also composed of epidermic cells in close juxtaposition, 
but round and finely dotted on their surface. Vegetations are 
nothing else than a development of the papillae of the epidermis, 



232 VEGETATIONS. 

and, in their anatomical composition, do not differ much from certain 
papilliform warts." 

Vegetations are most frequently met with upon the internal sur- 
face of the prepuce directly back of the furrow at the base of the 
glans ; they are also found upon the margin of the meatus, or within 
this orifice upon the walls of the fossa navicularis ; upon the vulva 
in women, and especially in the neighborhood of the carunculse 
myrtiformes; and, in both sexes, around the anus, upon the tongue, 
velum palati, and even within the larynx. 

Treatment. — The treatment of vegetations consists simply in 
their removal by the knife, caustic, or ligature, and the destruction 
of the base from which they spring. With the vegetations upon the 
internal surface of the prepuce, I have found it most convenient to 
touch them with fuming nitric acid, and repeat the application upon 
the fall of the eschar as often as may be necessary ; or, when promi- 
nent and pedunculated, they may be snipped off with scissors, and 
their base thoroughly cauterized, although, when cutting instruments 
are used, the hemorrhage is sometimes a little troublesome. As 
soon as the tenderness produced by the application of caustic has 
subsided, it is desirable to keep the glans uncovered in order to 
harden the internal layer of the prepuce by exposure to the air and 
friction ; and, unless the preputial orifice is very narrow, this may 
generally be accomplished by wearing for a few days a narrow ban- 
dage round the penis posterior to the glans. Special attention should 
also be paid to removing any collection of the smegma prwputii, and 
keeping the parts perfectly clean. 

The nitric acid acts so favorably, that I have seldom resorted to 
other caustics, with the exception of chromic acid, which has come 
into favor within a few years. 1 A solution of this acid (one hundred 
grains to the ounce of water) is a powerful escharotic, and is espe- 
cially useful in those obstinate cases in which the vegetation 
repeatedly returns after removal; but it should be applied with 
caution, simply moistening the surface of the morbid growth and 
sparing the healthy tissues in the neighborhood, or otherwise it is 
apt to induce severe pain and inflammation. 

I have sometimes employed a mixture of equal parts of dilute 
muriatic acid and tincture of the chloride of iron, which is one of 
the best escharotics for warts upon the hands in children. 

Vegetations about the vulva may be treated in the same way as 

1 See Dublin Quarterly Journal of Med. Science, vol. xiii., p. 250; Ranking's 
Abstract, vol. xxv., p. 149; New Orleans Med. News, Nov., 1867. 



TREATMENT. 233 

those upon the prepuce. When situated around the margin of the 
anus, they are generally of considerable size, and require to be 
snipped off with scissors before the application of acid to the base. 

As these pages are passing through the press, my attention has 
been called by a very reliable surgical friend to the efficacy of 
simply powdering the growth with dry calomel in the treatment of 
vegetations. Under this application, the warts are said to rapidly 
shrivel up and disappear. 

Vegetations during pregnancy may appear at quite an early period; 
they grow very rapidly, and often attain an immense size. I have 
seen a mass as large as a man's arm, extending from the mons veneris 
to the sacrum, and surrounding the vulva and anus. During ges- 
tation no operative procedure is admissible ; but the pain, itching, 
and offensive odor may be palliated by careful attention to cleanliness 
and lotions of diluted Labarraque's solution, or the application of 
some astringent powder, as equal parts of savin and burnt alum. 
After delivery, they often disappear spontaneously, or may be 
removed by the knife or caustic ; but when the mass is very large, 
only a portion should be attacked at a time. 1 

Vegetations situated upon a chancre or mucous patch cannot 
always be distinguished from those upon the sound integument ; but 
the history of the case, and, especially, the coexisting symptoms, 
will determine whether mercury is required to combat syphilitic 
infection of the general system. 

1 A re'sume* of the articles which have appeared upon vegetations in pregnant 
women may be found in the Gaz. Hedomadaire for Feb. 8, 1861. 



234 STRICTURE OF THE URETHRA. 



CHAPTER XIII. 

STRICTURE OF THE URETHRA. 

Having considered the complications of gonorrhoea, it remains to 
speak of one of the most frequent and important results of the same 
disease, urethral stricture. 

ANATOMICAL CONSIDERATIONS. 

An acquaintance with the anatomy of the urethra — including the 
character of its lining membrane, the fibrous, muscular, elastic, and 
erectile tissues which surround it, its dimensions and direction — is 
essential to a proper appreciation of the pathology of stricture and 
the skilful execution of operative procedures requisite in its 
treatment. 

The male urethra is naturally divided into three portions, viz., the 
prostatic, membranous, and spongy. 

The prostatic urethra is the portion included in the prostate gland, 
and generally, but not always, traverses this body at the union of its 
middle and upper thirds. Its length in the adult is about one inch 
and a quarter ; its posterior boundary is a prominence of the mucous 
membrane, called the uvula vesicae ; its cavity is fusiform, largest 
in the centre, and somewhat contracted towards either extremity. 
Upon its floor, a short distance in front of tne uvula, is an abrupt 
elevation of the mucous membrane and subjacent tissue, which 
forms a ridge three-fourths of an inch in length, and which gradually 
subsides as it approaches the membranous urethra. This prominence 
is known as the veru montanum, crista urethrse, or caput gallinaginis. 
It contains erectile tissue, connected with that of the corpus spon- 
giosum, and is adapted to assist in the closure of the urethra at this 
point, and prevent the passage backwards of the semen during 
coitus. Directly in front of the summit of the veru montanum, is a 
small sac or pouch, three or four lines in depth, which is called the 
"sinus pocularis," and also, from its probable homology to the 



ANATOMICAL CONSIDEKATIONS. 



235 



Fig. 5. 



womb, the " uterus masculinus." 1 The ejaculatory ducts traverse the 
walls of this cavity and open upon its margin. On each side of the 
veru is a depression called the " prostatic sinus," in which are found 
the orifices of the prostatic ducts, from twenty to thirty in number. 

The membranoiis urethra extends from the apex of the prostate to 
the bulb, and is nearly or wholly included within the two layers of 
the deep perineal fascia. It is about 
three-fourths of an inch in length 
on • its upper, but is shorter on its 
lower surface, owing to the encroach- 
ment of the bulb upon the latter. It 
is narrower than any other part of 
the urethra, except the meatus, and 
in consequence of the greater devel- 
opment and number of muscular tis- 
sues surrounding it, possesses in a 
higher degree the power of contrac- 
tion. This characteristic has led 
some authors to give it the name 
of the "muscular region" of the 
urethra. 

The spongy urethra, inclosed in the 
erectile tissue of the corpus spon- 
giosum, varies in length according 
to the degree of turgescence of the o/fiw/ 
penis; in a state of relaxation, it 
usually measures about five inches ; 
during erection, it may attain seven 
or eight. The posterior portion of 
this region is somewhat dilated, es- 
pecially on its inferior aspect, and 
has received the name of " the sinus 
of the bulb." The term "bulbous 
portion" is also applied to the pos- 
terior inch of the spongy urethra. 
The ducts of Cowper's glands open 
near its centre. Besides being some- 
what dilated, the sinus of the bulb 
is extremely dilatable. This may 



Cowpei** GhmZ. 




Meatus 



The bladder and urethra laid open, 
from above. (After Gray.) 



1 The most recent philosophical anatomists confirm the analogy bet-ween the 
prostatic vesicle and the uterus. For an able resume" of this subject, see Simpson, 
Obstetric Memoirs and Contributions, vol. ii., p. 294. Philadelphia, 1856. 



236 



STKICTURE OF THE URETHRA. 



be shown by two casts of the urethra in fusible metal, the one taken 
while the canal is simply filled, the other while it is forcibly dis- 
tended by the metal. The difference in the size of the part corre- 
sponding to the bulb will exhibit the dilatability of which it is 
susceptible. "Wood-cuts of two casts thus taken may be found in 
the London Lancet (Am. ed.), Aug. 1851, p. 97. Anterior to its sinus, 
the spongy portion maintains a nearly uniform diameter until within 
about an inch of the meatus, where it again enlarges and forms the 
"fossa navicularis." Lastly, the external orifice or "meatus" is a 
narrow vertical slit, which is the most contracted part of the whole 
canal. In some rare instances, however, the smallest diameter is 
found about a quarter of an inch within* the meatus, where it can of 
course be seen. 

The mucous membrane lining these various regions is continuous 
posteriorly with that of the bladder, and anteriorly with the covering 
of the glans penis. It is very delicate in its structure, and abun- 
dantly supplied with bloodvessels and nerves, which render it highly 
vascular and sensitive. Numerous glands ("glands of Littre"), 
racemose in their structure, 1 are found in the spongy and mem- 
branous, and mucous follicles in the prostatic region, the secretion 

from all of which constantly lubricates the 
passage. Fossae or lacunae of the mucous 
membrane, apparently destitute of glandu- 
lar structure, are also found upon the upper, 
and more numerously upon the lower sur- 
face of the urethra. They may sometimes 
be traced for nearly half an inch beneath 
the lining membrane, and their mouths are 
commonly directed forwards. One, larger 
than the rest, and called the "lacuna magna," 
is situated on the upper aspect of the canal, 
from half an inch to an inch posterior to 
the meatus. These lacunae, especially when 
dilated by long-continued inflammation, may 
obstruct the passage of a sound and lead to 
the formation of false passages. The ure- 
A. Superior surface of urethra. tnral mucous membrane is covered with the 
g. Fossa navicularis. c. Probe cylindrical form of epithelium. Except in 

inserted in D, the lacuna magna. ,i . .• _ .-i • i 

'After Phillips.) tne prostatic region, this membrane is ar- 

ranged in longitudinal folds, which are 

1 Kolliker, Manual of Human Histology, published by the Sydenham Soc, vol. 
iL, p. 236. 



Fie. 6. 




.SPONGY UEETHRA. 237 

generally in contact, and close the canal, the latter appearing on a 
transverse section of the penis as a mere star or slit. The fact that 
the urethra, under ordinary circumstances, is collapsed, and cannot 
be said to constitute a tube except when distended, is of importance 
with reference to the method of using injections in gonorrhoea. 
Unless the meatus be compressed, it is hardly possible that the 
urethral folds should be thoroughly opened, so that the fluid may 
come in contact with the whole mucous surface and the mouths of 
its lacunas; and unless this be accomplished, injections can be of but 
little avail. 

According to Mr. Thompson, the rugae of the mucous membrane 
"appear to be connected wi$h the existence of numerous long and 
slender bands of fibrous tissue, which are seen lying immediately 
beneath the mucous membrane, for the most part in a longitudinal 
direction. In the bulbous and membranous portions they are ex- 
tremely delicate, constituting these the weakest parts of the urethral 
wall, a fact worthy of remembrance in connection with the use of 
instruments." ] In the bulbous region the danger of doing violence 
is increased by the dilatability of the passage, and by the presence 
of the firm anterior layer of perineal fascia just beyond it. 
• The dimensions and direction of the urethra, taken as a whole, 
will be better appreciated after considering other tissues which sur- 
round it. 

The urethra is mvested by " unstriped, organic, or involuntary" 
muscular fibres, one layer of which is separated from the mucous 
membrane throughout its whole course, merely by elastic and areolar 
tissue ; while in the prostatic and spongy regions, a second layer is 
found external to the prostate and corpus spongiosum; the two 
being united in the membranous region. These fibres were first 
noticed by Kblliker, 2 in 1848, and afterwards more fully described 
by Mr. Hancock. The first series of fibres above mentioned is con- 
tinuous posteriorly with the inner muscular layer of the bladder 
while " the outer layer of the muscular coat of the bladder passes 
forwards on the outside of the prostate gland, to assist in forming 
the organic muscular covering of the membranous portion of the 
urethra ; whilst superiorly, or on the upper surface of the gland, 
these external longitudinal fibres are arranged in two or more bun- 

1 Pathology and Treatment of Stricture of the Urethra, 2d ed., London, 1858, p. 
12. I am greatly indebted to this unrivalled monograph for much that is contained 
in the present chapter upon stricture. 

8 Beitrage ziir Kenntniss der glatten Muskeln, Zeitschrift fur Wissen, Leipzic. 1848, 
Band i., p. 67. 



238 STRICTURE OF THE URETHRA. 

dies, which are attached to the pubes near its symphysis. From the 
front of the prostate the conjoined layer of muscular fibres passes 
forwards to the bulb, investing the membranous portion of the 
urethra, covered by, but distinct from the common muscles of the 
part, the latter being inorganic, voluntary, or striated ; these being 
organic and nucleated. Arrived, however, at the bulb, these two 
layers again part company, and extend forwards through the whole 
length of the spongy portion of the urethra, the internal layer run- 
ning between the corpus spongiosum itself and the urethra, but 
separated from the latter by areolar tissue ; the external lying on 
the outside of the corpus spongiosum, separating the proper spongy 
tissue from its fibrous investment. Upqn reaching the anterior ex- 
tremity of the urethra, these two layers again unite, and form a 
circular body or band of organic muscular fibres, constituting that 
peculiar structure usually denominated ' the lips of the urethra,' and 
which had previously been considered by Mr. Guthrie as surrounded 
by a peculiar dense structure, analogous to that which forms the 
edge of the eyelid, and which, he believed, was requisite to maintain 
the patency of the opening ; so that not only have we the urethra 
supplied by a coat of organic or involuntary muscular fibre, but the 
spongy body itself lies between its two layers of involuntary mus- 
cle ; an arrangement, doubtless, of very great importance, in relation 
to the due performance of the functions of the part." 1 

The demonstration of this continuous layer of muscular tissue 
surrounding the whole course of the urethra, is of the highest 
importance, both with reference to the treatment of stricture and 
the influence which muscular spasm may have in its production. 

Involuntary muscular fibre also enters largely into the composi- 
tion of the prostate gland, of which it is said to constitute no less 
than two-thirds, and of the laminas or "trabeculse" of the corpus 
spongiosum ; and although its primary function may be to evacuate 
the secretion of the glandular structure of the prostate on the one 
hand, and, on the other, blood which has served the purposes of 
erection, yet it can scarcely be doubted that it may also act as a 
sphincter and compress the urethra in the prostatic and spongy 
regions. 2 

The corpus sjtongiosum is dilated at its posterior extremity where 
it forms the bulb ; and since the urethra, leaving the membranous 
region, enters this portion nearer its upper than its lower surface, 
the larger part of the erectile tissue at this point is found below 

1 Hancock, Strictures of the Urethra, London, 1852, p. 16. 

2 Thompson, op. cit., p. 44. 



CORPUS SPONGIOSUM. — CORPORA CAVERNOSA. 



239 



the canal. The corpus spongiosum terminates anteriorly in an 
expansion, called the " glans penis ;" while a thin layer of erectile 
tissue is continued backwards around the membranqus portion of 
the urethra and extends into the veru montanum of the prostate. 

Fig. 7. 




The accompanying diagram, drawn by Mr. Thompson from a dis- 
. section upon the dead body, exhibits the depth and position of the 
bulb, and its relation to the rectum ; a matter of no small impor- 
tance with reference to operations upon this part. 

The corpus spongiosum consists of a vast number of venous 
sinuses, communicating with each other in all directions. Its great 
vascularity explains the hemorrhage which is liable to ensue, when 
the spongy, and also the membranous, portion of the urethra is 
divided by the knife of the surgeon or accidentally wounded. This 
occurrence, however, is less likely to take place, when an incision is 
confined to the mesial line; either in consequence of the fibrous 
partition which separates the two lateral portions of the vascular 
tissue at this point, or, as suggested by Mr. Thompson, because the 
two branches of the pudic artery, which lie one on either side, are 
thus avoided. 

The corpora cavernosa are two in number. Arising in front of the 
tuber ischii, and intimately united to the periosteum covering the 
rami of the ischium and pubis, the two unite in front of the sym- 
physis, to which they are connected by the suspensory ligament, 



240 



STEICTURE OF THE URETHRA. 



and are continued forwards as far as the corona glandis, where 
their common extremity is capped by the expansion Of the corpus 
spongiosum forming the glans. The vascular connection between 
these bodies is. free, though little, if any, exists between them and 
the corpus spongiosum, which lies in a groove upon their under 
surface. 

Deep Perineal Fascia. — The triangular space, seen in the bony 
pelvis to intervene between the pubic and ischiatic rami, is occupied 

Fig. 8. 




1, 1, 1. Flaps of the divided superficial fascia. 2. Anterior layer of deep perineal fascia. 
3. Urethral opening. 4. Position of Cowper'| glands behind anterior layer of deep fascia. 

by a tense, fibrous septum, constituting one of the chief supports of 
the pelvic viscera above, and known by the various names of 
•'deep perineal fascia," "triangular ligament of the urethra," "Cam- 
per's ligament," " middle perineal fascia," " an o -pubic aponeurosis," 
etc. This septum is composed of two layers, separated by an 
interval in wnich are found the membranous portion of the urethra, 
which necessarily passes through the deep perineal fascia to arrive 
at the surface, the compressor urethrae muscle, Cowper's glands and 
ducts, the arteries of the bulb, and the dorsal vein, nerve, and artery 
of the penis. We might. familiarly liken this septum to a double 
window, through which a funnel, representing the urethra, passes ; 
in which case the portion of the funnel contained between the sashes 
would correspond to the membranous region. 

At their apex, the two layers of the deep perineal fascia are thin 
and firmly attached to the sub-pubic ligament and pubic bones; 
they then pass downwards and backwards, and are stretched between 



DEEP PERINEAL FASCIA. 



241 



the pubic and ischiatic rami. The space between them, containing 
the important parts already mentioned, is from half to three-fourths 
of an inch in depth. The vena dorsalis penis pierces the fascia 

Fig. 9. • 




(After Gray.) 



half an inch, and the urethra usually at about an inch below the 
symphysis ; but, according to measurements made by Mr. Thomp- 
son, the latter distance may vary from seven-eighths to an inch 
and a quarter; a difference of some importance as affecting the 
sub-pubic curve of the urethra. From the urethral opening two 
processes are sent off, one anteriorly to inclose the bulb, and the 
other posteriorly to become continuous with the fibrous capsule 
which surrounds the prostate gland. The inferior margin, or base 
ol the deep perineal fascia is directed towards the rectum, and sends 
oft a thm fascia which covers the inferior surface of the levator 
am muscle; its anterior layer winds round the transversus perinei 
and, thus' doubled on itself, becomes continuous with the superficial 
perineal fascia. 

16 



242 



STRICTURE OF THE URETHRA. 



Superficial Perineal Fascia. — Strictly speaking, there are two 
layers of this fascia, the superficial and deep. The former consists 
of cellulo-adipose tissue, belonging to the general integument of 



Fie. 10. 




Ante ricrZ aye r of 
Dtep. Perineal Fascia rcmcved- 
Shelving 

COMPRESSOR URETKRfi 
Jniernal Pudlc A rty. 
Arty of the Su.lt 

Con- pi r't Gla nd 



(After Gray.) 

the body. The latter is aponeurotic in its structure, and is chiefly 
important in its relation to the present subject. In accordance with 
frequent usage, it alone is intended by the term "superficial fascia 
of the perineum." This fibrous structure corresponds in its general 
direction with the deep perineal fascia just described, but is situated 
upon a more external plane ; behind the transversus perinei muscle 
it is continuous with the anterior layer of the latter fascia ; at the 
sides, it is attached to the rami of the pubic and ischiatic bones ; 
while in front it joins the dartos of the scrotum, the sheath of the 
penis, and the abdominal fascia. It also sends off processes which 
invest the transversus perinei and the muscles about the root of the 
penis. 

The relations of the superficial fascia to the penis have been more 
fully described than elsewhere, in the first volume of the Transac- 
tions of the American Medical Association, by Dr. Gurdon Buck, of 



SUPERFICIAL PERINEAL FASCIA. 



243 



New York. As this paper is not generally accessible, and deserves 
a much wider circulation than it has received, I shall quote the 
greater part of it. 

" The anatomical structure in question consists of a distinct mem- 
branous sheath investing the penis in the manner to be described, 

Fig. 11. 




(After Gray.) 

and forming a continuation of the suspensory ligament above, and 
of the perineal fascia below, and will be best understood by a 
description of the mode of dissecting it. 

•• The penis and scrotum are to be circumscribed by an incision 
at the distance of three fingers' breadth all around, and crossing the 
perineum at the anterior margin of the sphincter. 

"The dissection of the skin and subjacent cellular and adipose 
tissues is to be made towards the penis, on the level of the fascia 
lata laterally, and of the perineal fascia posteriorly, and carefully 
continued to the body of the penis, as far as the corona glandis. 
By this means, the penis, as well as the suspensory ligament, is 
denuded of its loose movable investments. 



244 



STRICTURE OF THE URETHRA. 



"An incision is then to be made along the dorsum of the penis, 
exactly in the median line, splitting through the suspensory liga- 



Fig. 12. 




Grf Sacro 'Sciatic Ligt- 



Superficial Perinea/ Artery 
—Sup&ficia I Perineal Nerve 
Internal Pudie N&rve 
Internal Fudic Artery 



(After Gray.) 

meat, and extending forward to the corona between the dorsal ves- 
sels and nerves that rnn parallel on either S1 de. The adhesionsof 
the sheath along the dorsum are firm, and require careful dissection 
the bloodvessels and nerves being raised with it, serve as a guide to 
show the line of adhesion. . 

"The dissection being prosecuted laterally as wellas interiorly 
and at the extremity, the entire corpus cavernosum is enucleated 
the muscles of the perineum being raised with the sheath. It is 
now clearly seen that the suspensory ligament from above, and the 
perineal fascia from below and laterally, form one continuous mem- 
brane with the sheath, inclosing the corpus cavernosum in its cavity, 
and embracing the corpus spongiosum urethra between two layers, 
one of which passes above, and the other below it. The excavated 
base of the glans adheres inseparably to the outer surface of the 
sheath, while, by means of its inner surface, it caps the summit ot 
the corpus cavernosum. 



SUPERFICIAL PERINEAL FASCIA. 245 

" Its adhesions are most firm at the extremity of the corpus caver- 
nosum, along its dorsal surface, and at the insertions of the erector 
and accelerator muscles. It is thickest around the corona, along the 
dorsal surface, and where it forms the suspensory ligament. Zones 
of vessels run at regular intervals in the direction of the circum- 
ference of the penis, from the dorsal trunks to the corpus spongiosum, 
between the layers of the sheath. The cavity formed by the sheath, 
and occupied by the corpus cavernosum, is limited posteriorly by 
the triangular ligament (deep perineal fascia). 1 

"That portion which covers the perineal muscles, and has been 
described by authors under the names of the superficial fascia of 
the perineum, inferior fascia and ano-penic fascia, arises laterally 
from the ascending rami of the ischium, and descending of the 
pubis, as far forward as the inferior edge of $he symphysis, where 
the two layers meet and form the suspensory ligament. Posteriorly, 
it is continued over the transverse muscle, and folding around its 
1 edges is prolonged upwards into the ischio-rectal fossa. 

" It also sends off from its upper surface membranous septa be- 
tween the accelerator muscles in the middle, and the erectors on 
either side, to join the triangular ligament, and thus forms three dis- 
tinct and independent sheaths that are confounded anteriorly with 
the common sheath investing the corpus cavernosum." 

M. Jarjavay has more recently confirmed Dr. Buck's observations, 
and gives full credit to the "Chirurgien de l'Amerique" for the 
originality of his discovery. 2 

Eichet, 3 while agreeing with Dr. Buck in the main, differs from 
him in some particulars. He states that the posterior portion of this 
fascia is quite loose and areolar upon the dorsum, where it cannot be 
distinguished from that covering the pubes ; and that thus a com- 
munication is opened by which infiltrations of urine may gain the 
sub-integumental cellular tissue of the penis and abdomen without 
-perforating the fascia. 

The spaces intervening between the fasciae now described may be 
said to constitute natural reservoirs, to which infiltrations of urine 
and collections of matter, consequent upon rupture of the urethra 
or inflammation in its neighborhood, are chiefly confined ; this being 

1 It would thus appear that the process of the anterior layer of the deep perineal 
fascia which is prolonged upon the bulb finally unites with the superficial fascia ; 
and it is so stated by Velpeau, "Traite" complet d'Anatomie Chirurgicale," Paris, 
1837, tome second, p. 216. 

2 Jarjavay, Traite" d'Anatomie Chirurgicale, Paris, 1854, tome second, p. 576. 

3 Richet, Traite" d'Anatomie Medico-chirurgicale, 2d ed., Paris, 1860. 



246 STRICTURE OF THE URETHRA. 

true at the outset of such effusions, and possibly so throughout their 
whole course ; although in many instances the aponeurotic wall is 
eventually ruptured, or opened by a process of ulceration, when a 
more extensive diffusion of the contents takes place. The practical 
deductions from the direction and connection of these fascial planes 
are therefore of great importance. They may be briefly stated as 
follows : 

Urine extravasated in the membranous or prostatic region, either 
advances towards the pelvic cavity through the fibrous sheath in- 
closing the prostate, or reaches the triangular space by the side of 
the rectum called the ischio-rectal fossa ; in the latter situation, it is 
still, in most instances, deeply situated in the substance of the peri- 
neum ; if it gain the surface it may extend around the union of the 
deep and superficial fascia, and be found in the cellulo-adipose tissue 
external to the last named fascia. 

The superficial and the anterior layer of the deep perineal fascia, 
united behind the transversus perinei and attached on each side to 
the ischiatic and pubic rami, form a pouch with its outlet looking 
forwards and upwards, where purulent or urinary abscesses may 
form in consequence of rupture of the urethra anterior to the trian- 
gular ligament, and from which they can only extend into the scro- 
tum or over the abdomen, the close attachment of the abdominal 
fascia to Poupart's ligament obstructing their passage down the 
thighs ; occasionally, however, the matter breaks through this barrier, 
and has been known to descend nearly to the knee. 

The presence of urine in the pouch just mentioned, is, however, 
for the most part secondary ; when first extravasated anterior to the 
deep perineal fascia,' it is confined within the aponeurotic structure 
described by Dr. Buck, where it may be felt as a firm, hard swelling 
situated beneath the superficial cellular tissue, which retains its 
natural suppleness and mobility. " Left to itself, the swelling some- 
times gradually approaches the surface by appropriating to itself by 
adhesive inflammation the successive layers of cellular tissue cover- 
ing it, and at length evacuating • its contents externally through an 
ulcerated opening. This, however, is not uniformly the case. It 
often happens that the ulcerative process within the abscess goes on 
in advance of the adhesive and conservative process on the outside 
and opens a communication into the loose cellular tissue covering it, 
the consequence of which is rapid extravasation in every direction, 
filling up the scrotum, spreading up over the pubes, and sometimes 
extending along the crest of the ilium as high as the false ribs. It 
is probably rare that this extensive secondary form of extravasation 



VOLUNTARY MUSCLES. 247 

is not preceded by the circumscribed or primary form, hence the 
importance of the established rule of practice — to make a free open- 
ing into these hard swellings along the urethra as soon as their 
existence is ascertained. Another, and much more rare consequence 
of an opening of the urethra into the sheath, is the gradual forma- 
tion of one or more fistulous tracks along the penis, terminating 
behind the corona glandis, and causing a good deal of thickening 
and induration of the tissues along their course." 1 

Voluntary Muscles. — It would be inconsistent with the limits of 
the present chapter to describe at length the various muscles which, 
correctly or incorrectly, have been supposed to act upon the urethra. 
Their anatomy is easily understood, and may be found in any ana- 
tomical text-book. Their physiological action is admirably de- 
scribed in Mr. Thompson's excellent monograph. The chief points 
of their relation to our present subject may be stated in a few 
words. 

The compressor uretlirx — including under this name the transverse 
muscular layer described by Mr. Guthrie, the descending fibres of 
Mr. Wilson, and the circular fibres of Miiller — is a sphincter of the 
urethra surrounding the membranous region, and performing the 
same office for the bladder that the sphincter ani does for the rectum. 
Cod traction of this muscle may contribute to the production of spas- 
modic stricture ; it often opposes the passage of an instrument, or 
renders its introduction painful, even when there is no obstruction 
in the canal ; it limits, to a great extent, the penetration of urethral 
injections from without, and prevents the exit of fluids injected \>y 
means of a catheter into the prostatic urethra. 2 

The anterior fibres of the levator ani, described by some authors 
as an independent muscle, under the name of " levator or compressor 
urethra?," encircle the prostate and neck of the bladder like a sling, 
and may assist in closing as well as elevating this portion of the 
urinary canal. 3 

The bulbo-cavernosus, by means of fibres which surround the corpus 
spongiosum and the corpora cavernosa, may exercise a similar office 
for the posterior portion of the spongy urethra. 

The muscles now mentioned are voluntary, and act under the 
direction of the will ; but the great abundance of organic muscular 
fibre, distributed around the urethra in situations already described, 
and the phenomena attendant upon the passage of urine and semen, 
leave no doubt that contraction of the urethra may take place as a 
purely reflex action. 

1 Buck, op. cit., p. 370. 2 See page 112. 3 Thompson, op. cit., p. 23. 



248 STRICTURE OF THE URETHRA. 

Dimensions, Mobility, and Direction of the Urethra. — Having con- 
sidered the separate portions of the urethra and the various tissues 
which surround it, we may now regard it as a unit; and more 
especially with reference to the size and form of instruments 
required in the treatment of stricture. 

The statements of authors relative to the length of the male 
urethra range from five and a half to twelve inches. This discre- 
pancy may be accounted for by the different methods employed in 
taking measurements ; whether upon the living or dead subject ; by 
the amount of traction exercised upon the parts ; and also, to a cer- 
tain extent, by an actual variation in different persons. The size of 
the penis appears to have no influence upon the length of the urethra ; 
the latter, as shown by Sappey's observations, 1 often being in an 
inverse ratio to the former. The greatest source of variation is 
found in the length of the anterior or ascending portion of the sub- 
pubic curvature. Without seeking for any absolute standard, it is 
desirable to obtain an average which may assist in determining the 
situation of strictures, and afford useful information in their treat- 
ment ; and after all that has been said by authors of the variable 
length of the urethra in different individuals, the results of measure- 
ments are found to be nearly identical, provided the method of 
making them be always the same. 

The length of the urethra may be estimated during life by means 
of a graduated catheter, the flow of urine indicating when the eye 
near its point has reached the vesical extremity of the canal, and 
care being taken that the penis is not stretched upon the instrument. 
After death, the urethra and bladder may be removed from the 
body, slit open superiorly, gently extended upon some smooth sur- 
face, allowed to contract by their own elasticity, and then measured 
with a tape. Attempts have also been made to ascertain the length 
of the urethra by casts of the canal in fusible metal ; but the two 
methods just mentioned are far more reliable. 

According to the careful and minute observations of Mr. Thomp- 
son and Mr. Briggs, the results of measurements thus taken during 
life and after death are not identical ; by the former, the average 
" length is found to be seven and one-half-inches ; 2 by the latter, eight 
and one-half. This difference is constant, and may readily be 
accounted for by the different conditions under which the measure- 

1 Recherches sur la Conformation Exte*rieure et la Structure de l'Uretre de 1' Homme, 
Paris, 1854. 

a Leroy d'Etiolles obtained an average of eight inches from one hundred measure- 
ments during life by means of a graduated gum-elastic sound. (Des RStrecissementt 
de VUretre, $c, Paris, p. 5.) 



DIMENSIONS AND MOBILITY OF THE URETHRA. 249 

ments are taken. It is worthy of remembrance, " since all accurate 
researches into the pathological anatomy of stricture are, of neces- 
sity, confined to an observation of the parts after death, while, in 
relation to treatment, the measurement during life is that which 
alone must be remembered." 1 

The urethra cannot be said to have any fixed and absolute 
diameter, since its walls admit of greater or less expansion according 
to the amount of force exerted upon them. A No. 12 catheter or 
sound of the ordinary scale rarely fails to pass with ease, if the 
parts be healthy; and not unfrequently No. 15 will pass without 
difficulty. 

It is more important to be familiar with the relative than with 
the actual diameters of the different portions of the canal. The 
external orifice or meatus is almost invariably the most contracted 
part; so that whatever instrument fairly enters the urethra will 
pass through it, if no obstruction exists. Another important infer- 
ence from this fact is, that to restore to its original calibre by dila- 
tation one of the deeper portions of the urethra contracted by 
stricture, the meatus must be enlarged, which can generally be 
effected only by incision. The next narrowest point of the canal 
is at the junction of the bulbous and membranous regions ; while 
the middle of the prostatic portion, and the sinus of the bulb are 
the widest. 

The degree of mobility of different portions of the urethra is 
chiefly influenced by the attachments of the neighboring fasciae. 
The anterior part of the penis is free, and capable, in a flaccid 
condition, of assuming almost any position ; in its posterior tnird, 
however, this organ is connected with the symphysis, by the suspen- 
sory ligament ; with the ischiatic and pubic rami, by the crura of 
the corpora cavernosa, and with the anterior layer of the deep 
perineal fascia, by means of the bulb ; the spongy urethra may, 
therefore, be said to be fixed in proportion as it approaches the 
membranous region. The membranous region is the least movable 
of all, owing to its firm connection with the pelvis by means of the 
two layers of deep perineal fascia. The prostatic urethra is suscep- 
tible of some slight change of position, dependent upon the action 
of the anterior fibres of the levator ani, and the amount of urine ±n 
the bladder. 

In a flaccid condition of the penis, the urethra has two curves ; 
the first confined to the anterior, the second to the deeper portion 

1 Thompson, op. cit., p. 4. 



250 



STRICTURE OF THE URETHRA. 



of the canal. The former is simply due to the dependent position 
of the anterior part of the organ, and is effaced in a state of erection 
or when the penis is elevated to an angle of about 60° with the 
body. The latter may be called the sub-pubic curve from its 
position beneath the symphysis. Unless some degree of force be 
used to straighten the canal, this curve is permanent, and a know- 
ledge of its direction is essential in determining the proper form of 
instruments and the manner of their introduction. 



Fig. 13. 




ct Utriculua 



Cewper't Gland 



Pr*pt 



Vertical section of bladder, penis, and urethra. (After Gray.) 

The sub-pubic curve commences an inch and a half anterior to 
the bulb, attains its lowest point, when the body is in the upright 
position, nearly opposite the anterior layer of the deep perineal 
fascia, and finally ascends through the membranous and prostatic 
regions. According to the observations of Mr. Thompson and Mr. 
Briggs, it "forms an arc of a circle three inches and a quarter in 
diameter ; the cord of the arc being two inches and three-quarters, 
or rather less than one-third of the circumference." Mr. Thompson 
states that he has often found it more acute in spare men ; and in 



TRANSITORY STRICTURE. 251 

the corpulent, more obtuse ; that traction of the abdominal muscles 
exercised through the suspensory ligament may also render it more 
abrupt, whence the advantage of raising the shoulders when per- 
forming catheterization upon patients in the recumbent posture. 
The elevation of the bladder above the pubes in children, and the 
enlargement of the prostate so common in old men, also effect a 
change in the direction of the sub-pubic curve from its usual adult 
standard, and require therefore a corresponding variation in the form 
of instruments. • Swellings and abscesses about the lower extremity 
of the rectum, large hemorrhoidal tumors, and various other cir- 
cumstances may also operate in a greater or less degree to cause 
some change in the direction of this curve. 

STRICTURES. 

Strictures are most appropriately classified as Transitory and 
Permanent. A transitory stricture, as the name implies, signifies 
a contraction of the urethra, capable of undergoing complete reso- 
lution through the action of natural forces. A permanent stricture 
is one dependent upon an organized, and consequently durable 
change in the tissues composing the urethral walls. 

Transitory Stricture. — The elements of a transitory stricture 
are muscular spasm, and congestion or inflammation. Either may 
exist alone ; usually, both are combined. 

The observation of certain phenomena attendant upon strictures, 
and upon the introduction of instruments into the urethra, had, for 
many years, led surgeons to believe that spasmodic action was, in 
some instances, the sole cause of urethral contractions ; and that, 
in very many, it bore an important part in their production. At 
that time, however, the knowledge of muscular tissue surrounding 
the urethra was chiefly confined to the compressor urethrse ; conse- 
quently many authorities denied the influence of spasm, except 
perhaps in the membranous region, to which this muscle is limited. 
The subsequent discovery by Kblliker and Hancock of organic 
muscular fibres around the whole canal has shown the possibility, 
and, reasoning from analogy, the probability, that spasmodic con- 
traction may take place in any part of the urethra ; and repeated 
observation of facts of frequent occurrence leaves no farther doubt 
upon the subject. 

The phenomena of spasm are well known, and are the same in 
the urethra as in other parts of the body. Certain conditions of the 



252 STRICTURE OF THE URETHRA. 

general system predispose to it ; as, for instance, irritability of the 
nervous system, a gouty diathesis, congestion of the internal parts 
of the body from external influences ; as cold, moisture, etc. The 
exciting cause is generally some impression upon the sentient nerves, 
transmitted to a nervous centre, and returned through motor fibres, 
terminating in either voluntary or involuntary muscles. In the 
urethra, spasmodic action, sufficient to produce stricture, may take 
place in the sub-mucous layer of organic fibres common to the 
whole canal ; or, in the membranous region, in the striped fibres of 
the compressor urethras ; and, perhaps, to a less extent, in those of 
the acceleratores in the spongy region. 

"While performing catheterization upon irritable subjects, it has 
occasionally been observed by nearly every surgeon, that the instru- 
ment is grasped and temporarily held by the urethral walls, even 
when the canal is free from permanent obstruction. In this case, the 
sound, or catheter, acts as a foreign body, and the irritation which it 
produces is followed by contraction in accordance with the familiar 
laws of reflex action. 

In other cases, the eccentric irritation is caused by laceration, 
abrasion, or a wound of the lining membrane, such as may ensue 
from the rough use of a catheter, or other surgical instrument. 
This, of itself, may excite spasm ; or the same may be induced by 
contact of urine with the raw surface. The presence of some degree 
of congestion or inflammation, provided it be not sufficient to 
obstruct the canal, does not render the term " spasmodic stricture " 
inappropriate. 

Striking examples of spasmodic stricture are also met with as the 
result of irritation about the rectum, excited by the presence of a 
tapeworm, ascarides, haemorrhoids, fissure of the anus, fecal accumu- 
lation ; or by operations upon this part, especially the ligature of piles. 
Sir Benjamin Brodie 1 met with a case of spasmodic stricture, in 
which the spasm was intermittent, recurring every twenty -four or 
forty-eight hours, and which was finally cured by quinine after the 
failure of other means. % 

Among other causes of spasm, are the presence of a stone in the 
bladder, or urethra ; immoderate sexual intercourse ; the free use 
of alcoholic stimulants; long retention of the urine; horseback 
exercise ; digestive clerangements ; exposure to sudden changes of 
temperature, and mental emotion. 

A spasmodic stricture is characterized by its short duration. It 

1 London Medical Gazette, vol. i., p. 507. 



TRANSITORY STRICTURE. 253 

appears suddenly in persons of delicate habit, especially in those 
who have committed some imprudence in diet, and as suddenly dis- 
appears. Exploration of the canal by means of a sound after the 
spasm has passed, and frequently during its continuance, shows that 
there is no organic obstruction. Mr. Smith 1 details a case in which 
a patient, who had suffered from a violent attack of retention a short 
time before, suddenly died; and, at the post-mortem examination, 
not the slightest contraction was found. 

Swelling is so constant an effect of inflammation as to be reckoned 
among its characteristic symptoms. In every acute attack of ure- 
thritis, the calibre of the urethra must be more or less diminished ; 
and that this is a fact, is evinced by the diminution of volume in 
the stream of urine. The swelling of the mucous membrane is 
due in part to distention of its capillaries, and in part to infiltration 
of serum, or, sometimes, of more plastic material. Inflammatory 
products may become organized, and thus lay the foundation of 
permanent stricture; though, in most cases of acute gonorrhoea, 
they are soon absorbed, and the calibre of the urethra restored. 
Inflammatory or congestive stricture usually occurs in persons of a 
robust habit, in whom urethritis is decidedly acute, and is attended 
by very severe pain in the perineum and course of the urethra, and 
scalding in passing water; the penis is more or less turgescent, the 
lips of the meatus decidedly vascular, and the patient feverish. 

In the great majority of cases, however, which come under the 
observation of the surgeon, inflammation and spasm are combined 
or to these is added some degree of permanent contraction. A 
,patient has an organic stricture, which has given him but little 
annoyance, and offered no serious obstacle to the complete evacua- 
tion of the bladder ; suddenly, after freely indulging in spirits, or 
coitus, and retaining his urine for several hours, he finds himself 
utterly unable to pass water. The urethra, partially contracted by 
organized deposit in and around its walls, is entirely closed by the 
supervention of congestion and spasm, and complete retention is 
the result. Under appropriate treatment, the congestion and spasm 
may be subdued, though the organic stricture remains after their 
disappearance. 

The treatment of spasm and inflammation will be considered 
in the following pages, especially in connection with retention of 
urine, in the causation of which they constitute such important 
elements. 

i Henry Smith, Stricture of the Urethra, London, 1857, p. 23. 



254 STRICTURE OF THE URETHRA. 

Permanent or Organic Stricture. — The albuminous fluid 
which infiltrates the tissues in acute urethritis, and which may con- 
tribute to the formation of congestive stricture, is, in most cases, 
eventually absorbed, and the canal recovers its normal calibre. 
But under other circumstances, and especially as a consequence of 
chronic inflammation, products of a more plastic nature are thrown 
out, which become organized, exhibit the same tendency to contract 
as adventitious deposits in other parts of the body, and give rise to 
permanent contractions of the canal. 

The seat of this fibro-plastic deposit is commonly in the substance 
of the lining membrane, in the cellular tissue beneath it, and, in 
severe cases, in the more external tissues. Mr. Thompson's 1 observa- 
tions show that, in its incipiency, an organic stricture may consist 
of a mere thickening of the mucous membrane, hardly discernible 
when the urethra is laid open, and only evident on close inspection 
of a longitudinal section; at a stage slightly more advanced, the 
lining membrane loses its transparency, becomes puckered, is firmly 
adherent to the deeper tissues, and transverse fibres are found be- 
neath, which encircle the canal like a purse-string ; finally, in the 
most severe form, the meshes of the submucous tissue are filled 
with organized lymph, the fibres of organic muscle can no longer 
be detected, and the adventitious deposit may involve the substance 
of the corpus spongiosum, or even extend to the corpora cavernosa; 
giving to the penis a hard, nodulated feel, evident during life on 
external examination. 

This organized material is found under the microscope to be 
identical with inflammatory products effused in other parts of the 
body, the tendency of which to contract and harden is well known. 
Mr. Thompson compares it to the interstitial deposit in the liver 
producing cirrhosis, to the lymph poured out in pleurisy, and to the 
substance of cicatrices following burns. The nature of this tissue 
fully explains the admitted necessity of long-continued dilatation to 
restore the original calibre of the contracted part, and the constant 
tendency which strictures exhibit to return, when once apparently 
cured, a tendency which is so universal, that Cruveilhier 2 has pro- 
nounced stricture of the urethra absolutely incurable. It is evident, 
moreover, that the diminution in the calibre of the urethra is but 
one of the bad effects of stricture ; the normal elasticity of. the canal 
;s lost, and the exercise of its function seriously interfered with. 

In exceptional cases the urethra is obstructed by the deposition 

1 Op. cit., p. 55. 2 Anatomie Pathologique du Corps Humain. 



PERMANENT OR ORGANIC STRICTURE. 255 

of a false membrane within its walls without any external constric- 
tion, in a manner analogous to the effusion upon the trachea and 
bronchi in croup. Mr. Hancock 1 describes the appearance presented 
at several post-mortem examinations which he had the opportunity 
of making, as follows : " The membrane was straw-colored, and for 
the most part adhered so firmly to the mucous membrane, that it 
was only by careful dissection we could separate the one from the 
other; indeed, so identified were the two, that had we remained 
content with a mere cursory or superficial examination, we might 
have imagined the morbid appearances to have depended upon 
thickening and puckering of the mucous membrane itself, rather 
than upon what actually obtained. It was only by the microscope 
that we could determine what was really the condition of the parts. 
The existence of this false membrane was proved by some points of 
great interest ; among others, that although this newly-deposited 
structure appeared to be invested by mucous membrane when exam- 
ined by the naked eye, the investment, though smooth and shining, 
did not possess the actual organization of mucous membrane, but, 
when viewed through the microscope, presented more the character 
of condensed cellular tissue. It did not possess either villi or 
papillae upon its free surface; it was not -invested by epithelial 
scales; and, what was extremely interesting, as incontrovertibly 
proving the non-identity of this membrane with the proper mucous 
canal, we found that by carefully dissecting it away, we came down 
upon the layer of epithelial scales separating it, as it were, from the 
proper mucous membrane of the urethra." Occasionally, according to 
Mr. Hancock, the posterior portion of the membrane is detached, and 
may constitute a valve ; which, while offering little if any obstruc- 
tion to a sound, may completely cut off the passage of the urine. 
" Primary croup " of the urethral mucous membrane is admitted by 
Rokitansky, 2 who states that it chiefly occurs in children. Mr. 
Thompson, in his examination of pathological collections in various 
museums, has found but three specimens of stricture which coula 
be attributed to false membranes, and in two of these he is of the 
opinion that the appearances were due to dilated lacunae ; it is 
probable, therefore, that the cases described by Mr. Hancock are 
extremely rare. 

A deposition of an entirely different character from that jusi 
described — with which, however, it may be confounded — is noi 
unfrequently met with covering the urethral walls at the site of a 

1 Strictures of the Urethra, etc., London, 1852, p. 76. 

2 Syd. Soc. ed., vol. ii., p. 235. 



256 STRICTURE. OF THE URETHRA. 

stricture. It consists of a copious secretion of pasty mucus, "which 
may or may not be attended with an exuberant formation of epithe- 
lium, and in which, accordingly, the epithelium is either rapidly 
thrown off from an almost bare and t as it seems, excoriated mucous 
membrane, or accumulates over the whole or over parts of the 
surface, and thus forms a complete laminated covering for it, or 
patches of various thickness here and there upon it." 1 This pasty 
exudation is always the result of chronic inflammation, while the 
croupy deposit before described is due to that of an acute form. 

In former times, when pathological anatomy was rarely studied 
minutely upon the dead body, all strictures were supposed to be due 
to fungous growths within the canal, which encroached upon its 
diameter and presented an obstacle to the passage of urine and the 
introduction of instruments. Subsequent observation has shown 
that such excrescences are very rarely the cause of obstruction, 
although they are sometimes met with. They have been observed 
and described* by Soemmering, Laennec, Charles Bell, Leroy 
d'Etiolles. Amussat, Eicord, Mercier, Mr. Henry Thompson, and 
others. Dr. Gross 2 says that he has "several times -seen fleshy 
Growths in the urethra ;" and, from my own experience, I can testify 
to the not unfrequent occurrence of vegetations in the fossa navicu- 
laris in persons bearing similar growths upon the preputial mucous 
membrane. In this situation, however, I have rarely found them to 
seriously affect the exercise of the urethral function. 

These "fungi, carnosities, caruncles, or excrescences," as they 
have been variously termed, may consist of a development of the 
mucous papillae, like external warts upon the prepuce ; of ordinary 
granulations, springing from an ulcerated surface ; of true polypi ; 
and, rarely, of tubercular or cancerous growths. Mr. Thompson 
states that the first variety mentioned is most frequent in the spongy 
region ; that polypoid growths are confined to the prostatic urethra ; 
and that tubercle and cancer are never primary formations, but 
always consecutive to their development in other portions of the 
urinary organs. 

Strictures dependent upon varicose enlargements were at one time 
admitted, but their existence is not borne out by post-mortem exam- 
i nations. The hemorrhage which sometimes attends the introduc- 
tion of instruments, and is occasionally excessive, generally proceeds 
from vascular granulations, an abraded surface, or a wound of the 

1 Rokitansky, op. cit., vol. iii., p. 51. 

1 Practical Treatise on the Diseases, etc., of the Bladder, Prostate Gland, and 
Urethra, 2d ed., p. 759. 



SEAT. 257 

spongy tissue which surrounds a large portion of the urethra. It 
is probable that, in most Cases, there is increased fulness of the ves- 
sels in the neighborhood of a stricture during life, although it is not 
always apparent after death. 

Dr. Jameson relates the case of an aged seaman who had long 
labored under severe stricture and habitual retention, and at whose 
post-mortem, the " whole of the membranous portion of the urethra 
was found ossified, and reduced to the size of a crowquill." 1 Not- 
withstanding the high authority on which this statement is made, it 
appears to me probable that the appearances observed were due to 
the deposition of calculous matter imbedded in the urethral walls, 
and not to true ossification. 

Finally, stricture may depend upon specific induration surround- 
ing a chancre, concealed within the urethra ; of which Eicord states 
that he has met with many examples. 

Seat. — There are several sources of error which should be avoided 
in attempts to determine the anatomical seat of strictures during 
life. These are the difference in the estimated length of the normal 
urethra, as given by different authors ; the mobility of the stricture 
itself, which may often be thrust back to a considerable distance on 
the point of an instrument ; the liability of the penis to be elongated 
by traction at the time of taking the measurement ; and the actual 
elongation which often ensues as a consequence of the frequent 
handling which this organ receives from persons suffering under 
stricture. The great discrepancy in the statements of authors as to 
the most frequent seat of this complaint shows that these, and per- 
haps other sources of error have not been sufficiently guarded 
against ; and the tendency has almost invariably been, as shown by 
recent investigations, to assign to stricture a seat posterior to its true 
situation. 

I shall not waste time in quoting the different opinions which 
have been expressed upon this disputed point, but refer at once to 
the results obtained by Mr. Thompson from a careful and laborious 
examination of over three hundred preparations of stricture con- 
tained in the chief museums of Paris, London, and Edinburgh. It 
is only in this manner, by post-mortem inspection, that the locality 
of stricture can be ascertained with certainty and accuracy; and 
Mr. Thompson's conclusions will doubtless be regarded as decisive, 
until controverted by an examination of a still larger number of 

1 An Essay on Strictures of the Urethra, by H. G. Jameson, M. D., Surgeon to th<j 
Baltimore Hosp., Am. Med. Recorder, 1824, vol. vii., p. 251. 

17 



258 



STRICTURE OF THE URETHRA. 



specimens, conducted with equal care and fidelity — an event not 
likeiy soon to happen. 



Fig. 14. 



The spongy portion. 



The membranous 
portion. 



The prostatic 
portion. 




Region No. IIL 



B,e°;ion No. II. 



Region No. i. 



" A healthy urethra, eight inches and a half in length, slit up from the upper part, accurately 
reduced on scale from a drawing made from the original while fresh, to half the natural size. 
On the left-hand side are indicated the anatomical divisions of the urethra, and on the right 
the boundaries of the regions referred to in relation to the locality of stricture." (Thompson.) 

In relation to the locality of stricture, Mr. Thompson divides the 
urethra into the three following regions : — 

I. The Sub-pubic Curvature; which comprises an inch of the 
canal before, and three-quarters of an inch behind, the junction be- 
tween the spongy and membranous regions, thus including the whole 
of the membranous portion. 

II. The Centre of the Spongy Portion, a region extending 
from the anterior limit of the preceding, to within two inches and a 



SEAT. 259 

half of the external meatus, and measuring therefore about two and 
a half to three inches in length. 
III. The External Orifice, including a distance of two 

INCHES AND A HALF BEHIND IT. 

Of 270 preparations, embracing 320 distinct strictures, Mr. Thomp- 
son found 

In region I 216 or 67 per cent. 

" II 51 " 16 " " 

« in . . . 54 « 17 * » 



320 

It is thus seen that by far the largest number of strictures are 
situated at the sub-pubic curvature ; and the most frequent locality 
may be still further limited to the anterior portion of this region, as 
appears from the following statement by Mr. Thompson : " That 
part of the urethra which is most frequently affected with stricture 
is the portion comprised in the inch anterior to the junction, that is, 
the -posterior or bulbous part of the spongy portion. The liability 
of this part to stricture appears to diminish as it approaches the 
junction, where it is less common ; while behind, it is very rare. 
Most rarely is a stricture found so far back as the posterior part of 
the membranous portion." 1 The next most frequent situation of 
stricture is the external two and a half inches, and the least frequent 
the middle portion of the spongy region, although the difference 
between the two is not very great; while both are of but small 
importance compared with the anterior portion of the bulb. 

Mr. Walsh 2 has arrived at results identical with those of Mr. 
Thompson, from an examination of the preparations in the Eoyal Col- 
lege of Surgeons of Dublin ; and in reviewing the observations of 
other surgeons, it is found, as a general rule, that, whenever their 
statements have been based upon post-mortem investigation, they do 
not differ materially from those here given. 

M. Mercier, 3 who has probably paid more attention to the anatomy 
and pathology of the genito- urinary organs than any other French 
surgeon, states that strictures are almost exclusively limited to the 
spongy portion of the urethra, and are most frequent at the bulb. 
He believes that it is quite exceptional to meet with them as far 
back as the membranous portion. 

1 Op. cit., p. 83. 

2 Dublin Medical Press, Jan. 23, 1856, p. 51. 

3 Recherches sur le Traitement des Maladies des Voies Urinaires, 1856, p. 376. 
Also Bulletin de la Soci6te Anatomique de Paris, 1858, p. 441. 



260 STKICTURE OF TEE URETHRA. 

It will be observed that no mention has been made of ths pros* 
tatic portion of the urethra; a region which Sir A stley Cooper 
asserted was even second in the relative frequency of stricture. 
There can be no doubt that hypertrophy of the prostate was formerly 
mistaken, in many instances, for organic contraction of the canal ; 
and recent observations show, that stricture of the prostatic urethra 
is so extremely rare that doubts of its existence are not unreason- 
able. Mr. Thompson states unhesitatingly that there is not a single 
case to be found in any of the public museums of London, Edin- 
burgh or Paris. Mr. Walsh describes a preparation in the Museum 
of the Royal College of Surgeons in Dublin, in which a stricture 
commences in the posterior part of the membranous, and extends 
into the prostatic portion, causing a well-marked contraction. Mr. 
Crosse described and figured a case of prostatic stricture; Leroy 
D'Etiolles 1 and Ricord 2 say they have met with them; and Civiale 3 
speaks of one. 

In conclusion, it may be stated that modern investigation would 
appear to show that strictures are found only in those portions of the 
urethra which are surrounded by erectile tissue, and are most fre- 
quent where the latter is most abundant ; hence, their most common 
seat is in the bulb, next in the remainder of the spongy portion, and 
finally in the membranous region, which is also invested with a thin 
layer of vascular tissue. In harmony with this law, the thickest 
portion of a stricture surrounding the bulbous urethra is below the 
canal, corresponding to the greater thickness of the erectile tissue in 
this direction. 

Number. — In most cases there is only one stricture in the same 
subject. Of 267 preparations examined by Mr. Thompson, the stric- 
ture was single in 226. Occasionally there are several distinct con- 
tractions. Hunter 4 met with six; Colot with eight; and Ducamp 
with five ; but Boyer never found more than three, and Mr. Thomp- 
son 5 never more than "three, or at the most, four." Civiale 6 says 
that when there are several, one of them is almost always situated in 
the sub-pubic curve, and the others between it and the meatus. It 
is to be understood in these remarks, that distinct strictures are alone 
referred to. The urethra is sometimes contracted for a considerable 
distance, several points of which are more constricted than others ; 

* Des R6tr6cissements de l'Uretre, Paris, 1845, p. 83. 

2 Notes to Hunter on Venereal, 2d ed., Phil., 1859, p. 168. 

3 Maladies des Organcs Genito-urinaires, 2d ed., Paris. 1850, vol. i., p. 158. 
Ricord and Huntek, op, cit., p. 168. 5 Op. cit., p. 54. 6 Op. cit., vol. i., p. 157. 



FORM. 261 

but these are not to be regarded as separate strictures. Lengthy- 
strictures are more frequently found in the spongy region than in 
the sub-pubic curve ; and instances are recorded in which' they have 
extended from the meatus nearly to the bulb. 

Form. — The form of stricture necessarily varies with the amount 
and situation of the fibrinous deposit which produces it. This may 
consist of a few fibres, which encircle the whole or a part of the 
urethral circumference, like a thread, or may form a band, varying 
in extent and thickness. In the former case, the stricture, composed 
of a fold of mucous membrane inclosing the constricting fibres, has 
the appearance of a membranous diaphragm, which may embrace the 
whole or a part of the. canal — in the one case like a narrow ring, and 
in the other like a crescent ; it sometimes runs obliquely, instead of 
directly across the urethra ; occasionally it is pierced by one or more 
holes. This is the "linear stricture" of Mr. Thompson and others; 
the " bridle stricture " of Charles Bell ; and the " valvular stricture " 
of French writers. A rare variety of this form of stricture is a small 
narrow band stretched from side to side, or crossing the canal diag- 
onally, and dividing the urethra into two portions. Mr. Thompson 
speaks of a preparation in the Museum of St. Bartholomew's Hos- 
pital, in which there are ten or eleven of these free bands, which this 
author is inclined to ascribe to short false passages. These bridles 
are sometimes of considerable size, as in another preparation of the 
same museum, in which the urethra is contracted throughout its 
whole length, and a rough, fibrous band, an inch in length, and 
attached only by its extremities, extends from the verumontanum 
forwards, to the membranous part of the urethra. 

Where the fibrinous deposit is more extensive, the stricture 
covers a larger portion of the urethral walls. In some instances, it 
is abrupt on either side, like the last-mentioned form, but wider ; as 
if a whip-cord were tied externally to the mucous membrane ; this 
is called an " annular stricture." If the induration be more diffused 
around its base, a section of the canal will resemble an hour-glass, 
and the contraction receives the name of " indurated annular stric- 
ture." Mr. Thompson states that thickening of the tissues is gener- 
ally greater on the lower than on the upper surface. Again, stricture 
may involve the canal to the extent of half an inch or several 
inches ; when the passage is often more or less deviated from its 
normal direction, and the stricture is said to be " irregular or tor- 
tuous." It -is chiefly in these cases that the induration is so excessive 
as to implicate the whole thickness of the corpus spongiosum, or 



262 



STRICTURE OF THE URETHRA. 



even a portion of the corpora cavernosa, and form hardened masses 
which are readily perceived by the finger during life. 

Degree of Contraction. — The plastic material of stricture exhibits 
a constant tendency to contract, and become harder and firmer with 



Fig. 15. 



Fig. 16 





Fig. 15. Annular stricture. 

Fig. 16. Irregular, or tortuous stricture. Posterior to the stricture in each figure, are seen 
pouches of the mucous membrane, formed by dilatation of the lacunae and ducts, and capable 
of entangling the point of an instrument. (After Thompson.) 

time ; it is consequently true, as a general rule, that the longer a 
stricture has existed, the more callous it is, and the less susceptible 
of dilatation. Exceptions to this law, however, sometimes exist ; 
and strictures of long duration are met with which yield readily, 
while others, recent in their origin, prove very obstinate. Again, 
there is a class of strictures which are amenable to the process of 
dilatation, but which rapidly contract again, and in a very short time 
after the cessation of treatment, are as narrow as ever. They are 
most frequently found in the bulbous and spongy portions of the 
urethra, where the character of the surrounding tissues admits of a 
more extensive effusion of plastic material than in the deeper parts 
of the canal. They constitute the " resilient stricture " of Mr. Syme. 
When two strictures are present — one in the anterior, and the other 
in the posterior portion of the urethra — the latter will generally be 
found to dilate much more rapidly than the former. 

Complete obliteration of the urethra may take place as a conse- 
quence of a wound of the canal, sometimes from within, but more 



DEGREE OF CONTRACTION. 263 

frequently from without. In stricture, other than those of traumatic 
origin, the urethral walls are probably never completely fused 
together ; although cases are reported in which fistulous passages 
had for a long time turned the urine from its normal channel, and 
in which, on post-mortem examination, it was impossible to introduce 
the finest probe through the contraction, even after the external 
portion of the penis had been slit up. 1 Instances of this kind, how- 
ever, are rare ; in most cases, however great the narrowing, urine 
will still find its way out, though it may be only by a few drops at 
a time. 

There has been no little discussion of the question, whether the 
urethra, when permeable to urine, is always permeable to instru- 
ments, a question of importance in its bearing upon perineal section 
as advocated by Mr. Syme, Professor of Clinical Surgery in the 
University of Edinburgh. Some misconception of Mr. Syme's 
views has at times been entertained, and it has been supposed that 
he asserted the immediate permeability of strictures under all cir- 
cumstances. The true opinion of this surgeon will be best given in 
his own words. He says : " As to the question of ' impermeability,' 
I simply maintain, that if the urine passes out, instruments may 
always, through care and perseverance, be got in beyond the con- 
traction. It should be observed that the case here is quite different 
from that of a distended bladder requiring immediate relief. I have 
never maintained that in such circumstances the introduction of a 
catheter was always practicable." 2 

Mr. Liston previously took similar ground, and asserted that he 
had never seen impassable stricture ; " for, when any water comes 
away, you can, by patience and perseverance, get a catheter through, 
sooner or later." 

Dr. Phillips holds the same views as Mr. Syme. In his Traite des 
Voies Urinaires, 3 he says : " Mr. Syme asserts that no stricture is im- 
passable ; whenever the urine can find exit, even in a few drops 
only, a fine bougie can be introduced. I am entirely of this opinion, 
however absolute it may appear.' Dr. Phillips has acquired con- 
siderable reputation in Paris by performing catheterism in cases 
where Nelaton and other surgeons had failed ; but this success has 
been attained in some instances only after attempts repeated and pro- 
longed to a greater extent than is usually considered justifiable. In 

1 Thompson, op. cit., p. 60-1. 

2 Edinburgh Monthly Journal, June, 1851. 

3 Page 194. 



264 STRICTURE OF THE URETHRA. 

one case six sessions of three hours each were required, and when 
the reader is informed that Dr. Phillips always places the patient 
during catheterization in the standing posture, it will be seen that 
no small amount of endurance was required. 

Mr. Syme's views have not been generally adopted by the profes- 
sion at large. They have excited much opposition abroad ; and, in 
this country, I think I can safely say that no surgeon of any con- 
siderable experience will maintain that he has never seen an " im- 
passable stricture ; " yet the records of surgery will show that the 
surgeons of America are not behind those of other countries in skill 
and manual dexterity. In the latter years of his life, Mr. Liston 
was repeatedly foiled in attempts to introduce a catheter, and Mr 
Cadge, who assisted this surgeon in his operations for some time 
before his death, says : " I have notes of four cases in which, after 
repeated unsuccessful attempts to introduce an instrument, Mr. Liston 
secured the patients as for lithotomy, and opened the urethra by an 
incision in the perineum." The great advocate of permeability, Mr. 
Syme himself, has also been foiled, as will appear from the following 
confession in the second edition of his work : 1 "In many cases, I have 
had to wait days, or even weeks, before the passage could be hit. 
Indeed, on three occasions — one in private and two in public — I 
found it necessary to open the urethra anteriorly to the stricture, so 
as to obtain the assistance of a finger placed in the canal, to guide 
the point of the instrument." As intimated by one of his reviewers, 
"this is most suspiciously like a 'buttonhole' contrivance, and 
unavoidably suggests the idea of a back door in the operator's argu- 
ment." 

It is not intended by these remarks to disparage the skill, gentle- 
ness, and perseverance which will often triumph over an obstinate 
stricture, when less able hands have failed. It is to be recollected, 
too, that the greater the surgeon's confidence in his instrument, the 
more likely he will be to succeed. It may be admitted, also, that 
where the necessary qualifications are present, instances of failure 
are rare ; but to claim that such never occur, exceeds the bounds of 
truth, and is calculated to discourage the student in the use of the 
catheter. In the words of one of our most eminent surgeons, " I 
assert, upon the testimony of personal experience, the best test of all, 
that there is a class of strictures, the result of ordinary causes, which, 
while they admit of the passage of urine, slowly and imperfectly it 

1 Pp. 33-36. 



PATHOLOGY OF STRICTURE. 265 

may be, do not permit the introduction of any instrument, however 
small, into the bladder." 1 

After all, may it not be said with truth, that the difference of opinion 
upon this question is rather one of words than of facts ? 

PATHOLOGY OP STRICTURE. 

In mild cases of stricture, the canal in front of the contraction pre- 
serves its normal dimensions and character ; but in severe and chronic 
cases, when the flow of urine has been much obstructed, and the 
anterior portion of the urethra, either through sj^mpathy or con- 
tinuity of tissue, has participated in the inflammation which chiefly 
affects the part behind the stricture, it is contracted ; another con- 
dition, difficult of explanation, is one of dilatation, which, in a case 
described and figured by Charles Bell, was very considerable. In- 
stances in which the urethra was ulcerated in front of the stricture, 
are also given by the same author. 

Posterior to the stricture, the urethra is generally enlarged, as a 
natural consequence of the impediment to the free evacuation of the 
bladder. The canal ultimately loses its elasticity and becomes 
dilated so as readily to admit the finger, or even form a pouch 
which may appear as a fluctuating tumor in the perineum. Sii 
Benjamin Brodie relates the case of a patient who had a stricture 
at the distance of three inches behind the external meatus ; when- 
ever he made water, a tumor presented itself in the perineum, as 
large as a small orange, which was punctured with a lancet, and 
gave exit to a full stream of urine, which was allowed to flow through 
the artificial opening until the stricture had been effectually treated 
by dilatation. 2 The lacunae of the mucous membrane and the orifices 
of the prostatic and ejaculatory ducts frequently participate in this 
enlargement ; and the septa between the pouches thus formed con- 
stitute a network, chiefly confined to the floor and sides of the canal, 
which is well adapted to obstruct the passage of an instrument 
unless the point be well elevated towards the pubis. This condition 
is represented in Figs. 15 and 16, taken from Mr. Thompson's work. 
In consequence of continued pressure, the prominence of the veru- 
montanum may also be entirely effaced. The prostatic portion of 
the urethra is particularly susceptible of the dilatation now described, 
while the membranous is less so; indeed, when the stricture is 
situated in front of the triangular ligament, the latter portion may 
retain its normal calibre — a fact to be remembered in relation to 

1 Gross, Diseases of the Urinary Bladder, etc., 2d edition. Philadelphia, 1855, p. 763. 

2 Lectures on the Diseases of the Urinary Organs. Philadelphia, 1847, p. 12. 



266 STRICTURE OF THE URETHRA. 

perineal section, otherwise in performing this operation in cases of 
impassable contractions, dilatation of the urethra may be sought for 
as a guide to the incisions, when it does not exist. 1 When there 
are several strictures, the urethra is commonly somewhat dilated 
between them. 

The mucous membrane, especially behind the stricture, is the seat 
of chronic inflammation ; it is sometimes contracted and puckered ; 
and sometimes thin, and minutely injected with bloodvessels ; the 
surface is generally covered with a layer of pasty exudation, and it 
is from this source and from the bladder that the gleety discharge, 
which is so constant an attendant upon stricture, is derived. Ulcer- 
ation frequently takes place, which may be superficial, or which 
may extend to the deeper tissues, producing large and ragged exca- 
vations of the urethral walls, or, in rare instances, it may even occa- 
sion destruction of the contracted portion of the canal. A patient, 
under the care of Sir Benjamin Brodie, 2 suffered from very severe 
pain at the site of his stricture for several days, after which his 
condition was much improved and he passed water better than he 
had done for years ; the whole train of circumstances indicating 
that the stricture had been destroyed by ulceration. 

Abscess and Fistula. — A still more serious consequence of stricture 
is the development of abscess and fistula in the neighborhood of 
the urethra. In most cases their mode of origin resembles the for- 
mation of abscess and fistula around the rectum ; the urethral 
mucous membrane is impaired or destroyed at one or more points 
by ulceration ; during the straining of micturition, urine, perhaps in 
a very minute quantity, escapes into the cellular tissue ; an abscess 
is formed which burrows in various directions, or which opens and 
establishes a fistulous communication between the external surface 
and the urethra. In other cases abscesses are developed without 
rupture of the urethral walls or infiltration of urine ; and they may 
even occur, when the obstruction to the evacuation of the bladder 
is far from complete. They can only be ascribed to the irritation 
produced in the surrounding parts by the presence of the stricture, 
especially if this be heightened by a careless use of instruments. 
Numerous post-mortem examinations have shown that there may 
be no connection between an abscess dependent upon stricture and 
the urethral canal ; in many cases, however, a communication is 
subsequently established by the ulcerative process. When a urethral 
opening exists, it is generally behind the contracted part, but some- 
times in front of it. Instances of urinary abscesses anterior to 

1 Guthrie, London Lancet, Am. ed., Sept. 1851, p. 173. * Op. cit., p. 1G. 



ABSCESS AND FISTULA. 267 

strictures have been recorded by Civiale, 1 Caudmont, 2 and others, 
and occasional specimens are found in various public museums. 
The course taken by urinary fistulas is often very erratic ; they may 
open into the rectum, upon the perineum, upon the surface of the 
scrotum, the lower part of the abdomen, or upon the thighs or nates. 
Thompson 3 refers to two specimens, in one of which the fistula 
traversed the thyroid foramen, and in the other terminated at the 
umbilicus ; and a preparation was presented at the Societe de Chi- 
rurgie, of Paris (Sept. 21, 1859), in which a fistula, originating in 
the bladder, passed through the horizontal ramus of the pubis, and 
terminated by several openings in the thigh ; it is probable, how- 
ever, that the patient, in addition to his stricture, had disease of the 
pubic bone, to which the bladder had become adherent. 

These abnormal passages rarely have more than one opening into 
the urethra, but very frequently a number upon the external surface ; 
in one case, seen by Civiale, the latter amounted to no less than 
fifty -two. 4 Their internal surface becomes lined with adventitious 
tissue, which bears a very close resemblance to mucous membrane, 
but is destitute of glands and follicles ; it is organized, well supplied 
with nerves, bloodvessels, and absorbents, and constantly secretes a 
muco-purulent fluid. Their walls are so firm that the passage can 
often be traced like a cord underlying the skin. When numerous, 
the cellular tissue between and around them may become condensed 
through chronic inflammation into a hard, brawny mass, and the 
natural suppleness, if not the shape of the part, be lost. If the 
urethra be impermeable, the urine flows entirely through these 
abnormal channels ; if pervious, more or less may still trickle away 
with each evacuation of the bladder. Calculous matter is deposited 
in fine particles or in larger masses, resembling mortar, upon the 
walls, and more particularly near the orifices or in some blind pouch 
opening into the passage. 

Deposition of similar matter often takes place in the dilated 
sinuses of the prostate already described. This gland, moreover, 
may become inflamed, and abscesses form in its substance, which 
may remain for a long time circumscribed, open into the urethra, 
or effect a communication with the rectum or cellular tissue of the 
pelvis ; or the prostate may be reduced to a pultaceous mass sur- 
rounded apparently by a membranous pouch, in which its normal 
structure can no longer be distinguished. Stricture of the urethra 
was formerly considered a frequent cause of senile enlargement of 

! 

1 Op. cit., p. 505. 2 Bulletin de la Soc. Anatomique de Paris, 2e s6rie, t. iv., p. 109. 
» Op. cit., p. 68. * Op. cit., vol. i., p. 539. 



268 STRICTURE OF THE URETHRA. 

the prostate, but numerous examinations of the dead and living 
subject 4 have shown that the two rarely coexist, and that there ia 
probably no connection between them. 1 

.Bladder. — That increased action shall be followed by increased 
development is a general law of the animal economy. For the same 
reason that the blacksmith's arm grows large and powerful, the 
vesical walls become hypertrophied, as a consequence of the obstruc- 
tion to the flow of urine and the additional force requisite for its 
expulsion induced by stricture. This hypertrophy chiefly affects 
the muscular layer, but does not wholly spare the areolar tissue, 
which is somewhat thickened and increased in density. The walls 
of the bladder may attain five or six times their normal thickness, 
and measure from half an inch to an inch in thickness. The 
developed fasciculi of muscular fibres form prominent ridges upon 
the mucous surface, and have been aptly compared to the columnae 
carneae of the heart's cavities. Frequent and violent expulsory 
efforts cause protrusion of the mucous membrane between these 
columns, and pouches are formed, which, small at first, may gradu- 
ally increase in size until they equal or excel the dimensions of 
the bladder itself. Their devolpment is favored by the fact that 
they are chiefly composed of mucous membrane with an imperfect 
layer of muscular fibres, a little areolar tissue and the peritoneum 
externally, and are therefore thinner, weaker, and less resistant 
than the proper vesical coats. There are frequently from three 
to six of these pouches, and sometimes many more; their com- 
munication with the bladder is often through a very small opening, 
which, in a preparation in the London Hospital Museum, does 
not exceed an ordinary goose-quill ; in many instances they contain 
sandy particles, or fully formed calculi, which may have found 
entrance from the bladder, or, more frequently, are developed in the 
cavity. Eupture of their walls, escape of urine into the abdominal 
cavity, and consequent death, have been known to occur. 2 

The imperfect evacuation of the bladder, in cases of stricture, and 
the consequent partial retention and decomposition of the urine, 
maintain the lining membrane in a state of chronic inflammation, 
which manifests itself, as in other mucous tissues, by hypertrophy, 
abnormal vascularity, increased secretion, and great irritability. 
On post-mortem examination, the mucous membrane of the bladder 
is found to be thickened, soft, and pulpy ; its color is heightened, 

1 Thompson, The Enlarged Prostate, its Pathology and Treatment, London, 1858, 
p. 58. Adams, The Anatomy and Diseases of the Prostate, London, 1853, p. 46. 

2 Preparation in George's Hospital Museum, No. S 21. (Thompson.) 



URETERS AND KIDNEYS — GENITAL ORGANS. 269 

generally of a dark-red hue, and much congested in patches; its 
surface is smeared with slimy mucus, which, when mingled with the 
urine, may obstruct the narrow orifice of the stricture ; scattered 
over it is a quantity of fine calculous matter, or it is covered with 
lymph, sometimes in small patches, at others, in layers of consid- 
erable extent. 

The irritability of the bladder excites to frequent acts of mictu- 
rition, and the capacity of this viscus, never fully distended, is 
eventually much diminished. Instances are recorded in which it 
would not contain more than an ounce, or even half an ounce, of 
fluid. When it has existed any length of time, this condition is 
but very imperfectly remediable, even if the stricture which caused 
it be successfully dilated, and the patient can never after have due 
control over his bladder. In exceptional cases, a contrary condition 
is produced ; if little or no irritability of the bladder be present, 
the impediment to the flow of urine may cause constant distention 
of this viscus, and its capacity be increased, instead of diminished ; 
in either case its walls are hypertrophied. 

Ureters and Kidneys. — As a stricture obstructs the exit of urine 
from the bladder, so it cannot but impede the passage of fluid into 
it ; consequently we find changes in the ureters and kidneys similar 
to those already described. The former are often so dilated that 
they will admit the finger or thumb, and, in some instances, have 
been mistaken for a portion of the small intestine; their parietes 
are thickened, and lymphy deposits, and other evidences of chronic 
inflammation are found upon their internal surface. The kidneys 
may participate in these lesions ; the pelvis, infundibula, and calices, 
are distended ; the medullary tissue of the organ is atrophied under 
the pressure to which it is subjected, and enormous reservoirs may 
be formed, capable of containing five, ten, and, in one instance, 
observed by Mr. Thompson, twenty ounces. 

Genital Organs. — Stricture is not unfrequently attended with 
hypertrophy and induration of the penis, and tumefaction and 
oedema of the prepuce. These lesions cannot be explained in an 
entirely satisfactory manner. Hypertrophy may be accounted for 
in many cases by the traction which patients suffering with stricture 
are wont to exercise upon the penis, but this doe3 not explain the 
induration ; and, in some instances, both hypertrophy and induration 
are present, when the habit referred to has not been practised. A 
similar condition of the parts is met with in certain affections of the 
prostate and neck of the bladder. Civiale 1 ascribes it to prolonged 

1 Op. cit., p. 141. 



270 STRICTURE OF THE URETHRA. 

•and frequent efforts to urinate, which obstruct the venous circula- 
tion, and maintain a state of chronic irritation or inflammation. 
The sympathy of the genito-urinary organs, one with another, has 
also, probably, some influence. The tumefaction of the prepuce is 
sometimes sufficient to require scarification. 

The ejaculatory ducts may be dilated ; their walls, and those of 
the vesiculae seminales, inflamed and thickened; and their cavities 
contain pus, and other products of inflammation. 

There is often considerable irritability of the testicle, and attacks 
of epididymitis sometimes occur, especially after the use of instru- 
ments within the urethra. Yelpeau 1 draws a distinction between 
epididymitis dependent upon gonorrhoea, and the present form ; and 
states that in the latter there is rarely effusion into the tunica vagi- 
nalis, and that the inflammatory symptoms, which are much less 
severe, usually disappear in five or six days, even without treatment. 
In my own practice, I have not found this difference to obtain. One 
of the most severe and obstinate cases of swelled testicle I ever saw, 
was due to the use of bougies in the treatment of stricture ; and I 
have met with others which have been very far removed from the 
Diild character described by Yelpeau. 

Constitutional Effects. — A person laboring under stricture in one 
of its more aggravated forms, is generally subject to more or less 
impairment of the digestive and nutritive organs. His appetite is 
defective ; his digestion imperfectly performed ; his tongue coated ; 
he loses flesh and strength ; has frequent attacks of chilliness, which 
sometimes assume a periodic type ; complains of pain and disagree- 
able sensations in various parts of the body, most frequently in the 
perineum, back, loins, thighs, and often in the sole of the foot ; he 
is low-spirited and anxious, and may eventually become a confirmed 
hypochondriac. To understand how stricture can affect distant 
organs, it is only necessary to recall to mind the importance of the 
renal secretion as a depuratory agent of the system ; and also the 
intimate connection which exists between the perfect working of all 
parts of the animal economy, whereby any defect in one is speedily 
manifested in others. It is evident from a consideration of the 
organic lesions which stricture induces in the bladder, ureters, and 
kidneys, that the secretion of urine must be seriously interfered 
with, and the perfect elimination of effete matter consequently pre- 
vented ; and it is also probable that more or less noxious material 
is absorbed from the partially decomposed urine which collects in 

1 Dictionnaire de M6d., t. xxix., p. 465. 



SYMPTOMS OF STRICTURE. 271 

the bladder and elsewhere. The inevitable effect of this upon the 
system at large, and especially upon the nervous centres, is too well 
known to require explanation. The solidarity of the genito-urinary 
and other organs is nowhere more evident than in ophthalmic prac- 
tice. Instances in which certain forms of eye disease, as asthenopia 
or choroiditis, coexist with, and clearly depend upon, an affection 
of the urethra, vagina, or uterus, are so common, that the expe- 
rienced oculist never fails to interrogate his patients respecting the 
condition of the latter organs, being convinced that no treatment of 
the eye disease can be successful, unless these be in a state of 
health. The same sympathy which here exists between the genito- 
urinary organs and the eye, must also extend to other parts of the 
system. 

SYMPTOMS OF STRICTURE. 

One of the earliest symptoms of organic stricture is generally a 
gleety discharge from the urethra. If the contraction of the canal 
has immediately succeeded an attack of gonorrhoea, the urethra may 
never have recovered its normal condition since the acute symptoms 
were present; but in some instances all traces of muco-purulent 
matter have entirely disappeared, or at least have not for some time 
attracted the notice of the patient, when suddenly, perhaps after 
some excess, the linen is found again stained, or the lips of the 
meatus adherent. The discharge, under these circumstances, may 
present all the varieties, in respect to character and the time of its 
appearance, already mentioned in connection with gleet. It may be 
constant, and sufficiently copious to soil the linen ; or very slight, 
and only perceptible on rising in the morning. It may be aggra- 
vated by violent or prolonged exercise, sexual intercourse, alcoholic 
stimulants, or atmospheric changes, and become so abundant and. 
purulent as to lead to the supposition that a fresh clap has been 
contracted ; and though, under favorable circumstances, it may nearly 
or quite disappear for a time, yet it soon returns, and does not per- 
manently yield to tlie ordinary treatment of gleet. This discharge 
is not a constant symptom of stricture, but is present in the great 
majority of cases. It is chiefly derived from the contracted portion 
of the canal, and the parts lying directly behind it, which are almost 
invariably the seat of chronic inflammation, and are more or less 
modified in their vitality. 

Another early symptom, and sometimes the first which attracts 
the notice of the patient, is a gradual diminution of the power, which, 



272 STRICTURE OF THE URETHRA. 

in a state of health, he possesses over the bladder in respect to mic- 
turition. He is not able to retain his water as long as usual, and a 
desire to urinate calls him up several times during the night. He 
attempts as usual to accomplish the act, when he finds that he must 
wait and make repeated efforts before the urine appears ; the stream, 
moreover, is diminished in fulness, is projected with less force than 
natural, and may be variously distorted ; sometimes it is flattened, 
at other times spiral like a corkscrew, forked, or divided into two 
or more portions which diverge from the meatus ; or, at the same 
time that a small stream issues from the canal, a portion falls in 
drops at his feet; he is obliged to take special care to avoid 
soiling his shoes and clothes; and, finally, when he supposes the 
act fully accomplished, a few drops dribble away, and wet his 
person and his clothing. The above symptoms cannot be regarded 
as pathognomonic of organic stricture, since they may be produced 
by other causes, as the presence of inspissated mucus in the canal, 
spasmodic contraction, calculi, irregular action of the bladder, etc.; 
still they are valuable indications, especially when persistent, and 
are generally, though not always, proportioned to the degree of 
the coarctation. 

At the same time, each passage of the urine is attended with pain 
and disagreeable sensations, which vary in intensity, position, and 
character. Most frequently there is a sense of dull aching in the 
perineum, back, and loins, or in the glans penis ; often pain of a 
sharper character is felt in the course of the urethra or at the neck 
of the bladder, or follows the course of the spermatic cord, and is 
most severe in the groins and testicles, while sometimes it shoots 
down the thighs. Another frequent seat of pain is behind the pubes, 
where it is probably due to some degree of inflammation of the 
bladder. In short, a condition of morbid sensibility exists in the 
urinary organs, and in the parts connected with them either by 
continuity of tissue or a common nervous supply. 

As the disease progresses, all the above symptoms are aggravated; 
and the urgency of micturition, especially, is much increased. Fre- 
quently, the patient is almost wholly deprived! of sleep by repeated 
calls to urinate, and the length of time which this act requires. In 
aggravated cases, the urine dribbles away in small quantities, while 
the patient is asleep, or without his consciousness during the day ; 
and he is first made aware of its passage by the wetting of his 
person. This has sometimes been mistaken for incontinence of urine ; 
whereas it is almost invariably due to distention of the contracted 
bladder and overflow of its contents. The urine also undergoes 



SYMPTOMS OF STKICTURE. 273 

certain changes in consequence of its retention and partial decompo- 
sition, and the vesical inflammation which is thereby excited. It 
is generally alkaline in its chemical reaction, of an offensive odor, 
cloudy, mixed with slimy tenacious matter which adheres to the 
sides of the vessel, and deposits on cooling a pale precipitate, which 
is found under the microscope to consist of crystals of the triple 
•phosphate, epithelium scales, and pus-globules. This condition of 
the urine is highly favorable to the deposition of calculous matter ; 
fine sand is often contained in the last portion of urine that comes 
away in micturition, and excites a scalding sensation in the urethra ; 
or calculi are formed, which may be retained in the bladder or 
become impacted in the dilated portion of the canal behind the 
stricture. 

Hematuria, which, however, is seldom excessive, sometimes occurs 
in connection with stricture, and is most frequently met with in old 
and aggravated cases in which the mucous membrane of the urethra 
is much congested. It chiefly follows the use of instruments which 
have probably wounded some vessel ; or the vascular tissues may 
be ruptured daring the turgescence of erection ; or, again, it may 
occur without appreciable cause. Sometimes, also, blood in small 
quantities is discharged from the mucous membrane of the bladder. 
These two sources of hemorrhage may generally be discriminated. 
If the blood come from the bladder, it is uniformly diffused through 
the urine, to which it communicates a dark color, or the latter 
portion of the stream is still more deeply tinged and contains broken 
clots ; frequently, also, there is pain and sensibility on deep pressure 
above the pubes. If it come from the urethra, it is found in the 
form of clots alone, or it may flow from the canal independently of 
the passage of the urine. 

The genital functions may be variously interfered with. In con- 
sequence of the irritation of the parts, frequent erections may take 
place, or nocturnal emissions occur. In other cases, erection is 
never perfect, owing to the rigidity of the urethra, or an obstruction 
to the entrance of blood into the corpora cavernosa ; pain is felt in 
sexual intercourse ; and the semen, instead of being at once ejacu- 
lated, slowly dribbles away, or passes backward through the dilated 
urethra into the bladder ; hence, persons with stricture are frequently 
impotent. Civiale remarks that ejaculation is followed by a 
momentary improvement in the power of urinating, but that the 
patient is left in a state of exhaustion, which frequently does not 
disappear for twenty -four hours. 1 

1 Op. cit., p. 167. 
18 



274 STRICTURE OF THE URETHRA. 

Haemorrhoids, prolapsus ani, and irritation about the rectum, which 
is occasionally severe, are often occasioned by the repeated and vio- 
lent straining required in emptying the bladder, and are thus indi- 
rectly symptoms of stricture. In a similar manner, hernia is liable 
to occur, especially in old men, and is a source of great annoyance, 
owing to .the difficulty of retaining the gut in place. 

Eetention of urine sometimes supervenes in the early stages of 
organic stricture, in consequence of congestion and spasm ; it may 
indeed, in rare instances, afford the first indication to the patient 
that he is the subject of stricture ; but in most cases it appears at 
a later period, when the obstruction to the passage of urine is 
already very great. It generally follows exposure to wet or cold, 
a long ride or drive, and, most frequently, a hearty meal, at which 
alcoholic stimulants have been freely indulged in, the kidneys 
stimulated to excessive secretion, the bladder distended, a tendency 
to congestion induced, and the urine long retained ; when, on 
attempting to urinate, the patient finds that he is utterly unable 
to pass water, or only in such small quantities that the bladder is 
not relieved from the internal pressure of its contents. The first 
few attacks of this kind may perhaps be remedied without much 
difficulty by the passage of a catheter, a hot bath, etc. ; and some 
patients, who are subject to retention, learn to relieve themselves, 
and carry an instrument habitually with them for the purpose. 
Sooner or later, however, with the progressive contraction of the 
stricture, an attack of a far more serious character occurs ; former 
means of relief are tried and found inefficient ; the bladder becomes 
more and more distended, and, unless incapable of dilating through 
excessive thickening and contraction of its walls, rises above the 
pubes, and forms a tense, ovoid tumor, which may reach as high as 
the umbilicus. The situation of the patient is now exceedingly 
critical; violent and fruitless efforts are made to urinate; pain 
already felt from the commencement of the attack along the course 
of the urethra, above the pubes, in the perineum, back and loins, 
becomes more general and more intense ; the body is covered with 
profuse perspiration and emits a urinous odor ; the face is flushed 
and anxious ; the eyes injected ; the whole aspect of the patient is 
one of terror and despair ; and, unless relief be obtained, the scene 
closes, in a few days, with delirium, coma, and death. The suffering 
induced by severe retention of urine surpasses the power of language 
to depict ; one only who has felt, or often witnessed it, can fully 
appreciate the agony. 

Distention of the bladder, in such cases, may even produce rup- 



SYMPTOMS OF STRICTURE. 275 

ture of the vesical walls. Two cases are reported by Sir Everard 
Home, two by Mr. Thompson, 1 and one in a recent number of the 
Medical Times and Gazette? If the peritoneum be involved in the 
rent, the urine gains entrance to the abdominal cavity ; the vesical 
tumor disappears, but the bowels are generally tense and swollen, 
and death soon occurs from peritonitis. More commonly the peri- 
toneum is spared, and the contents of the bladder are at first effused 
into the sub -serous cellular tissue, where they may cause extensive 
gangrene of the surrounding parts, or whence, they may afterwards 
escape into the abdominal cavity by ulceration. In no case of 
rupture of the bladder from retention, has the patient been known 
to recover. 3 

Still more frequently, the distention of the bladder produces 
rupture of the urethra behind the stricture, where its walls are 
weakened by chronic inflammation and ulceration. In the sudden 
and extensive infiltration of urine which ensues, no time is given 
for adhesive inflammation to erect barriers to its progress, as often 
happens in the slower formation of urinary abscesses, and thus the 
urine, forced on by the contractile power of the bladder, permeates 
the loose cellular tissue, wherever it is not limited by the fasciae, 
the influence of which in determining the course of urinary infiltra- 
tions has already been described. When the rupture takes place 
anteriorly to the triangular ligament, the effusion extends forwards 
and upwards into the scrotum and over the abdomen ; its extent 
may generally be defined by the swelling and discoloration of the 
integument, and an emphysematous crackling on pressure, which is 
due to the mixture of gases with the fluid; the vascular connection 
between the superficial and deeper tissues is cut off or impeded, and, 
unless free incisions be made, gangrene of extensive portions of the 
skin may ensue. Thus, cases are recorded, in which the effusion 
perforated the superficial perineal fascia and extended down upon 
the thighs, and in which the greater part of the integument from 
the knee to the umbilicus, including the coverings of the penis and 
scrotum, sloughed away, and left the testicles entirely exposed, and 
suspended only by the spermatic cords, and vessels ; yet, even under 
these circumstances, recovery has been witnessed. 

When rupture takes place posteriorly to the triangular ligament, 
the symptoms may for a time be obscure : as when occurring else- 
where, the patient often has the sensation of something giving way, 
and experiences temporary relief from his sufferings ; if the rent be 

1 Op. cit., p. 351. 2 F or Yeh. 11, I860. 3 Thompson, op. cit. 



276 STEICTUKE OF THE URETHRA. 

large enough to allow of the free escape of urine, the vesical tumor 
subsides, and, the tension of the parts being relieved, the patient 
may be able to pass water, but the quantity thus evacuated or drawn 
off is found to be small ; soon* deep throbbing pain is felt in the 
perineum, and symptoms of general depression set in ; and the urine, 
after burrowing in various directions, may approach the surface. A 
symptom, which is to be regarded as of very serious import, is the 
appearance of a dark spot upon the glans penis, which indicates 
that the infiltration has gained access to the corpus spongiosum 
urethrse, and that gangrene has already commenced. 

CAUSES OF STRICTURE. 

A knowledge of the causes of stricture, and the relative fre- 
quency of their action, may best be attained from an analysis of a 
large number of cases, such as is furnished in the following table 
prepared by Mr. Thompson. It should be observed that 143 of 
these 220 cases were collated from the records of University College 
Hospital, London, and 49 from reports by different surgeons in 
medical journals; they may, therefore, be regarded as free from any 
preconceived notions as to the etiology of stricture, and in a high 
degree trustworthy ; at the same time, occurring for the most part 
in hospital practice, they represent the worst class of urethral con- 
tractions. 

ANTECEDENTS, OR SUPPOSED CAUSES OF 220 CASES OF STRICTURE.* 

Gonorrheal Inflammation in 164 

Injury to Perineum ........... 28 

Cicatrization of Chancres or Chancroids ........ 3 

Ditto, following Phagedozna .......... 1 

Congenital, including cases in which the urethra may have been small from mal- 
formation, and those in which marked irritability of the urinary organs 
existed from childhood, accompanied by an unusually small stream . 6 
Poisoning by Nitrate of Potash* Lithotrity, Masturbation* of each one ... 3 
True Inflammatory Stricture, including temporary stricture and retention from 
sudden acute inflammation, usually caused by some excess, and disappear- 
ing by resolution •••••...... 8 

True Spasmodic Stricture, caused by irritation about the rectum ... 2 

" " " ho cause assignable ••..... 2 

" " " caused by undue acidity or alkalinity of the urine . 3 

220 



1 Thompson, op. cit., p. 124. 2 Medical Times, June 22, 1844. 

8 Lallemand, Clinique Me*dico-Chirurgicale, Ire part, p. 109. 



CAUSES OF STRICTURE. '277 

Of the 164 cases attributable to gonorrhoea — 

In 90 the disease is reported to have been chronic, or neglected. 
" 3 it was attributed by the patients to strong injections. 
" 6 the discharge is stated to have ceased entirely and rapidly under treat- 
ment ; but in five of these stricture appeared almost immediately 
after. 
" 4 other cases the stricture appeared to be almost simultaneous with the 
gonorrhoea. 
In the remaining 61 there is no report of chronicity, etc. 

Of the 164 cases attributable to gonorrhoea — 

10 appeared immediately after, or during the attack; 

71 " within 1 year of its occurrence ; 

41 " within 3 or 4 years; 

22 " within 7 or 8 years ; 

20 are reported at periods between 8 and 20 to 25 years. 

It appears from the above table that gonorrhoea holds the first, 
and injuries of the perineum the second rank in the etiology of 
stricture; and this inference is confirmed by the universal expe- 
rience of the profession at the present day. In a treatise" on vene- 
real diseases, it will only be necessary to consider the former of 
these causes, and the minor influence exerted by the cicatrization of 
venereal ulcers in the production of stricture. 

I. Commencing with gonorrhoea, let us ascertain, if possible, under 
what phases or circumstances this disease terminates in stricture. 
Here, again, Mr. Thompson's statistics accord with the observation 
of every surgeon, that urethral contractions are favored by the long 
continuance, rather than the severity, of urethritis. If we omit the 
61 cases of the above table in which there is no report of the dura- 
tion of the preceding gonorrhoea, we find that, in nearly nine-tenths 
of the remainder, the urethral inflammation, to which the stricture 
was attributable, was either chronic, or neglected. Inquiries ad- 
dressed to patients laboring under stricture show that, in the great 
majority, the urethral contraction has been preceded by several 
attacks of gonorrhoea ; but, whether by one or more, that the last 
was prolonged for many weeks or months, and terminated in a gleet. 
This coincides with what is observed in other mucous canals ; organic 
contractions of the lachrymal passages, of the oesophagus and rectum, 
are rarely, if ever, produced by acute, but almost invariably by 
chronic, inflammation ; whatever inflammatory products are effused 
in the former are albuminous, and admit of ready absorption, while 
those of the latter are fibrinous, and tend to become organized and 
permanent. 

This view is also supported by the fact that the most commou 
seat of stricture is at a distance of four or five inches from the 



278 STEICTURE OF THE URETHRA. 

meatus, since gonorrhceal inflammation during the acute stage is 
usually confined to the neighborhood of the fossa navicularis, while 
gleet affects the deeper portions of the canal, as shown by daily 
experience, and also by the post-mortem examinations of Roki- 
tansky and Mr. Thompson, who state that they have most frequently 
found the bulb the seat of chronic inflammation. The greater vas- 
cularity of this portion of the canal should be taken into account 
in this connection, since "the amount of inflammatory effusion may 
be assumed to correspond with the amount of blood supplied ;" and 
this will perhaps explain why stricture is not more frequently situ- 
ated in the membranous region. 

If the ground here taken be correct — of which I think there can 
be no doubt — it may be assumed that whatever prolongs the dura- 
tion of gonorrhoea, tends to produce stricture ; among the indirect 
causes of stricture, therefore, may be enumerated a strumous, rheu- 
matic, or gouty diathesis, imprudence in diet, indulgence in coitus, 
prolonged or violent exercise, acidity of the urine, irritability of the 
urethra resulting in repeated spasmodic contractions, etc. The 
influence of all these causes in aggravating urethral inflammation 
is either sufficiently obvious, or has been dwelt upon in the chapter 
upon gonorrhoea, and need only be alluded to at present. 

Laceration of the urethral walls during chordee, and wounds 
from the imprudent use of sounds, catheters, etc., require a passing 
notice. The former may occur spontaneously, or arise from the 
habit, more prevalent among Frenchmen than Americans, of relieving 
chordee by forcibly extending the penis; or, as is said, "breaking 
the chordee." Thompson states that he has met with an occasional 
example of stricture originating in this manner ; and, judging from 
the violent hemorrhage which sometimes follows this procedure, it 
may doubtless lacerate the canal to such an extent as to produce 
this effect. "Wounds of the urethra by instruments from within 
evidently have the same effect as from without ; in the process of 
cicatrization which ensues, the natural coaptation of the parts must 
frequently be lost, and fibro-plastic material endowed with contractile 
properties be deposited. 

The origin of gonorrhoea does not affect its liability to produce 
stricture, except so far as it influences its duration. Urethral con- 
tractions are as likely to follow urethritis occasioned by leucorrhcea, 
the menstrual fluid, acrid vaginal secretions, excess of venery, etc., 
as when the same disease is dependent upon direct contagion. This 
statement is founded not merely upon a belief in the simple nature 
of gonorrhoea, but upon observation ; and there is not, moreover, 



CAUSES OF STRICTURE. 279 

the slightest evidence that the plastic material of stricture (except in 
a class of cases to be mentioned presently) is of a specific character, 
nor is it influenced by the internal administration of mercury, 
which speedily acts upon the specific induration of secondary 
syphilis. 

A class of cases is referred to by Mr. Thompson, as of occasional 
occurrence — though less frequent than is commonly supposed — in 
which organic stricture appears at a late period of life, when there 
has been no urethritis for very many years before ; and the question 
is asked whether any relation exists between the two in the way 
of cause and effect. Mr. Thompson adopts the probable explana- 
tion, that a predisposition to congestion and inflammation may 
remain after an attack of gonorrhoea in youth, and be kept up by 
free habits of living, frequent exposure to atmospheric changes, 
an acrid condition of the urine from dyspepsia or gout, or by 
other causes, and finally result in the slow development of stric- 
ture, which does not manifest itself until many years after the acute 
attack. 

Much influence in the production of stricture has been attributed 
to the use of injections. I feel obliged to dissent in toto from this 
opinion, which appears to me to be based alone upon reasoning pest 
hoc ergo propter hoc. It is asserted in its support, that the greater 
number of patients with stricture have employed injections for the 
preceding gonorrhoea ; but even if this were proved to be true by 
the necessary statistics, it would not be conclusive to establish a 
connection between the two, while injections continue, as now, to be 
the favorite treatment of clap ; it would rather prove that stricture 
follows gonorrhoea, which is incapable of being cured by injections 
But that the statement referred to is an exaggeration — at least so far 
as concerns strong injections — may, I think, be fairly inferred from 
the above table of Mr. Thompson, in which it appears that of the 
164 cases of stricture attributable to gonorrhoea, in only three "was 
it stated by the patients that they attributed the complaint to their 
use, notwithstanding the disposition which patients commonly mani- 
fest to refer the cause of their disease to any particular mode of 
treatment, rather than to their own indiscretions, while in by far the 
larger proportion it was stated that their previous gonorrhoeas had 
not been combated by any kind of injections." 1 When made very 
strong, or used at an improper stage of the disease, or with excessive 
force, they may doubtless act as escharotics, or aggravate the inflam- 

1 Thompson, op. cit., p. 116. 



280 STRICTURE OF THE URETHRA. 

matory action, and thus favor urethral contraction, Kit this effect 
pertains alone to their abuse. At the present day, however, this 
prejudice against injections may be regarded as nearly exploded ; 
the most eminent modern surgeons employ them in their practice 
and highly recommend them, and I am happy to quote in their 
favor so high an authority as Mr. Thompson, who would naturally 
look at the subject from its stricture aspect, and whose opinion 
may therefore be regarded as unbiassed by any partiality for the 
use of injections in gonorrhoea. This surgeon says: "I have no 
hesitation in asserting that the proper employment of injections is 
one of the best modes of combating urethral inflammation, espe- 
cially in the chronic form, and thus of preventing the occurrence of 
stricture." 

II. A chancre or chancroid, like any other ulcer, destroys a cer- 
tain portion of the tissues upon which it is situated, and this loss of 
substance is not restored in the process of cicatrization, but the gap 
is filled with fibro-plastic deposit, in the form of granulations, which 
gradually contracts and approximates the edges of the original sore, 
or which forms a hard unyielding cicatrix between them. In this 
manner venereal ulcers situated upon any portion of the urethral 
mucous membrane may lay the foundation of stricture. Examples 
are most frequently seen in sores upon the margin of the meatus, 
and the more destructive the ulcer, the greater the liability of the 
urethral orifice to become contracted; hence chancroids, and espe- 
cially phagedenic chancroids, are more to be feared than chancres, 
since the latter, as a general rule, are more superficial. The same 
cause of stricture may sometimes be recognized within the canal at 
a greater or less distance from the meatus, and it is extremely pro- 
bable that it exists in other cases which are mistaken for simple 
gonorrhoea, although the discharge is really due to a concealed ulcer. 

Though a chancre upon the urethral mucous membrane may not 
occasion sufficient loss of substance to produce a stricture in the 
manner now described, yet it possesses another attribute capable of 
effecting the same result. The specific induration which underlies 
it and surrounds it, may destroy the normal elasticity of the urethral 
walls and present a serious obstacle to the flow of urine, and the 
introduction of instruments. Several instances of this kind have 
been observed by Ricord. 1 In some cases, doubtless, a stricture may 
be due to both these causes combined, viz., the cicatrix of an exca- 
vated ulcer, and specific induration. 

1 Hunter and Ricord on Venereal, 2d ed., Phil., 1859, p. 172. 



DIAGNOSIS. 281 



DIAGNOSIS. 



The general symptoms alone might be considered sufficient to 
indicate a case of stricture, but in many instances are very deceit- 
ful. There are £her affections of the urinary organs, the symptoms 
of which closely resemble those of stricture, and which have often 
been mistaken for it. Experience, therefore, would show that the 
greatest care should always be employed in forming a diagnosis. 
The diseases which are most likely to be confounded with organic 
stricture, are subacute inflammation of the prostate, and urethral 
neuralgia and hyperesthesia, which have received due attention in 
other chapters of this work. I merely desire at present to glance 
at a few important points. 

Subacute inflammation of the prostate may be attended by nearly 
every symptom, which has been described as belonging to stricture,, 
viz., by frequency and difficulty of micturition, gleety discharge, 
and pain in the perineum, above the pubes, and elsewhere. This 
identity in the symptoms may readily lead to a mistake in diagnosis, 
which may even be confirmed by a superficial exploration of the 
urethra; for the prostatic portion of the canal, in this affection, is 
exceedingly sensitive and the introduction of a catheter attended 
with severe pain ; if, then, the surgeon yields to the feelings of the 
patient and fails to make a thorough examination, or, if he employs 
a fine sound or bougie, the point of which is liable to be obstructed 
by catching in some lacuna of the mucous membrane, the erroneous 
conclusions already drawn from the history of the case, may appa- 
rently be confirmed. 

The same mistake may also occur in cases of urethral hyperaes- 
thesia, either when occasioned by sympathetic irritation from stone 
in the bladder, affections of the rectum, etc., or when, in the absence 
of any apparent cause, the exalted sensibility can only be attributed 
to nervous derangement. The diagnosis of a suspected case of 
stricture can, therefore, only be founded upon a careful and thorough 
exploration of the urethra, and the instruments required in such 
examination, and the manner of using them, will now claim our 
attention. 

Exploration of the Urethra. — The instruments requisite for phy- 
sical exploration of the urethra and the diagnosis of stricture are a 
set of catheters or sounds — and preferably both — ranging from 
No. 1 to No. 12 or 15 of the catheter scale in ordinary use ; a good 
supply of gum-elastic bougies, and several sounds with bulbous 
points. 



282 



STRICTURE OF THE URETHRA. 



Catheters are best constructed of virgin silver, which permits of 
their being bent to any desired curve. They are conveniently made 
somewhat longer than the canal they are designed to traverse, and 
usually measure about eleven inches. The surgeon should possess 
a prostatic catheter which is at least fifteen inch^ in length. The 
handle of the catheter is provided with a firm oval ring attached to 
each side, in order that the least twisting of the instrument on its 
axis after its introduction may be at once manifest to the operator ; 
and also to permit of its being retained as a permanent catheter. 
The vesical extremity of the instrument has two eyes for the escape 
of urine, one situated half an inch, and the opposite one an inch 
from the extremity. They are often made too large, and allow of 
the protrusion of folds of the lining membrane of the canal, ob- 
structing the passage of the catheter, and exciting unnecessary pain. 
Their edges should be bevelled off with nicety. Instead of these 
two lateral eyes, the end of the catheter is sometimes pierced with 
numerous small apertures, which are objectionable on account of 
their liability to become clogged with blood or mucus. 

The degree of curvature of this and other instruments used in 
urethral exploration is a matter of no small importance. It would 
seem desirable that the curve should correspond to the natural cur- 
vature of the least movable portion of the urethra itself, which is 
that portion underlying the symphysis pubis. Mr. Thompson has 
adopted this principle in the construction of catheters, and his 

Fig. 17. 




example has of late been very generally followed, since it has been 
found that experience confirms the deductions from theory, and that 
urethral instruments with such a curvature are most readily intro- 



sounds. 283 

duced. When speaking of the anatomy of the urethra, the sub-pubic 
curve was described as an arc of a circle three and a quarter inches 
in diameter, the chord of the arc measuring two inches and three- 
quarters. The accompanying figure from Mr. Thompson exhibits a 
catheter and sound so bent as to correspond to this curve. 

In order that the precise direction of the point of the instrument 
may be indicated by the direction of its shaft, it is desirable that a 
constant relationship should exist between the two. According to 
the principle of construction here recommended, this is a right angle 
in the catheter, and in the sound, a somewhat shorter instrument, an 
angle of 120°, or a right angle and a third. 

It is desirable to have one or more catheters graduated in inches 
and fractions of an inch, in order to measure the depth at which 
strictures are situated, and to determine the length of the urethra ; 
when used for the latter purpose, the graduation should commence 
with the terminal opening, and not from the extreme point. 

Gum-elastic catheters, which may be rendered stiff by a stylet, 
are sometimes used, but are not so generally applicable as those of 
silver. 

An ingenious substitute for a catheter available upon an emer- 
gency, has been proposed by Dr. Stearns, of N. Y., and consists 
simply of a piece of ordinary bell- wire doubled upon itself and bent 
tc a proper curve. If this be introduced into the bladder, the urine 
will escape between and at the side of the two wires. 

Sounds of solid silver are the best, but too expensive. They are 
generally made of steel, which should be pure and highly polished, 
to avoid the action of rust. To answer this requisite they are 
sometimes silver plated, but this does not afford reliable protection 
and it is better that they should be "polished in oil" rather than 
burnished. The handles of sounds should be broad and roughened, 
so as to afford a firm hold to the hand, and indicate any deviation 
in the direction of the point. As sounds are not intended to enter 
the bladder, except for the occasional purpose of ascertaining the 
presence of stone, they may be half an inch shorter than catheters, 
but should follow the same curve. 

Benique's sounds have^a double curve corresponding nearly to 
the two curves of the urethra when the penis is not elevated against 
the pubes, and, in short, are of the same shape that a flexible bougie 
assumes when introduced into the bladder and abandoned to itself. 
I am very partial to these instruments, and have a set in my office 
for common use, graduated according to Charriere's^foere, in which 
each sound exceeds the preceding by one-third of a millimetre in 



284 STRICTURE OF THE URETHRA. 

diameter. Since it is rarely, if ever, desirable to employ a metallic 
sound in strictures which are very much contracted, the lowest 
number of the set is 12, or one four millimetres in diameter ; the 
highest being No. 30, or ten millimetres in diameter. All numbers 
below 12 are supplied by gum-elastic bougies. In the dilatation of 
stricture, a set of instruments like these, increasing in size more 
gradually than those in common use, is extremely desirable. 

Bougies are made of wax, whalebone, elastic gum, and other 
materials, and terminate at the extremity in a blunt, conical, fusiform, 
or olive-shaped point. Gum-elastic bougies are generally preferable, 
except for very narrow strictures, where those of catgut or whale- 
bone are employed, as firmer and less liable to bend or break. In 
the absence of other kinds, the surgeon may manufacture wax 
bougies by soaking a piece of fine linen, of suitable length and 
width, in melted wax, and afterwards rolling it upon a hard surface 
into a cylinder. Bougies thus constructed are especially convenient 
for applying caustics to strictures. 

A twisted or corkscrew form may be imparted to the extremity 
of a bougie by winding it round a wire and retaining it in place 
for a few moments. This form is of great value when the opening 
in the stricture is at one side of the centre of the canal. It was first 
recommended by Leroy d'Etiolles, 1 and whalebone bougies of this, 
shape are always employed by Dr. Phillips in difficult cases. 

I am partial to olive-pointed bougies, which are introduced with 
great ease and freedom from pain, a matter of some importance with 
nervous patients, or when the urethra is very sensitive. The con- 
traction posterior to the olive-shaped extremity is also well adapted 
to carry to the deeper portions of the canal any lubricating or 
medicinal substance with which the bougie is smeared. 

All bougies, and especially those made of fragile materials, should 
be carefully examined from time to time, and if found impaired in 
the slightest degree should at once be destroyed, lest they be in- 
cautiously use"S. and a portion break off in the canal. Bougies of 
elastic gum become rough with use, whereby they irritate tho 
mucous membrane, and should, in this case, also be discarded. 
Whalebone bougies must be oiled occasionally, or they become 
brittle and unsafe. 

Bulbous sounds, made of steel, are serviceable in determining the 
extent of a stricture from before backwards, and also in ascertain- 
ing if a second stricture exists posterior to one already discovered. 

1 Sur les Avantages cles Bougies Tortille'es et Crochues dans les Re'tre'cissements 
et Angusties de l'Uretre difficiles a franchir, Paris, 1852. 



INTRODUCTION" OF THE CATHETER. 



285 



It is desirable to have several of them on hand, with the diameters 
of the bulbs varying from Nos. 1 to 6 of the catheter scale. At the 
suggestion of Dr. Geo. A. Peters, of this city, Messrs. Tiemann and 
Co. have recently manufactured a bulbous sound with a fine stem, 
upon which bulbs of different sizes may be screwed. The staff 
should be graduated in inches, commencing with the upper surface 
of the bulb, which is abrupt in this direction. The distance of the 
anterior edge of the stricture from the meatus having been measured 
upon a graduated catheter, a bulbous sound is passed through the 
contraction, when the position of its posterior edge can be deter- 
mined by the bulb catching upon it in a to-and-fro motion imparted 
to the instrument ; the difference in the readings upon the catheter 
and sound at a point corresponding to the external orifice of the 
canal will clearly indicate the length of the stricture. This measure- 
ment is always desirable to aid in determining the probable duration 
of treatment, and is almost indispensable when external or internal 
incisions are employed. Again, the small size of the shaft gives to 
bulbous sounds, when passed through one contraction, considerable 
freedom of motion, and enables the operator to explore for strictures 
more deeply situated. 

Bulbous bougies of gum elastic can be introduced with less pain to 
the patient than bulbous sounds, and are, therefore, to be preferred, 
especially for exploring the deeper portions of the canal. These 
and knotted bougies (" bougies a nceuds ") are very valuable instru- 

Fig. 18. 




Bulbous and knotted bougies. 1 (After Phillips.) 

ments for detecting a slight degree of contraction, and for deter- 
mining the comparative sensibility of the different portions of the 
urethra. 



Introduction of the Catheter. — A catheter may be introduced while 
the patient is in the standing or sitting posture, but the recumbent 
position is on many accounts the best ; the patient lying square on 

1 These and the other instruments mentioned in this work may be obtained of Mr. 
Geo. Tiemann, 63 Chatham St., N. Y. 



286 STRICTURE OF THE URETHRA. 

the back, with the shoulders elevated, the knees drawn up and 
somewhat separated, the genital organs entirely exposed, and the 
surgeon standing or sitting on his left. The operator now raises 
the penis to an angle of about sixty degrees with the body, thereby 
effacing the anterior curve of the urethra, by means of the ring and 
middle finger of the left hand, its palm looking upwards ; the thumb 
and forefinger are thus left free to retract the prepuce and separate 
the lips of the meatus. The catheter, previously warmed and oiled, 
is held lightly. between the thumb and fore and middle fingers of 
the right hand, "like a pen," its shaft corresponding to the fold 
between the abdomen and the left thigh. The introduction of the 
instrument should be slow, and with the exercise of but very little 
force; its own weight is almost sufficient to effect its passage > if 
properly directed ; if any obstruction be met with, the instrument 
should be withdrawn for a short distance and again advanced with 
the direction of its point slightly varied ; or if the obstacle be due 
to spasmodic contraction of the urethra, it may generally be over- 
come by gentle pressure continued for a moment or two; while 
passing through the first two inches of the urethra the point of the 
instrument is inclined to the lower surface in order to avoid the 
lacuna magna ; beyond this it should be directed rather to the upper 
surface to escape the sinus of the bulb; when it has penetrated 
beneath the pubis, the shaft is brought round to the median line of 
the body and parallel to the surface of the abdomen ; the handle is 
now to be elevated to a perpendicular and then depressed between 
the thighs, when the point will usually glide into the bladder ; if 
any difficulty is met with at this stage of the proceeding, it is pro- 
bably because the point has caught in the extensible tissue of the 
bulb, and the instrument should be again raised to a perpendicular 
and slightly withdrawn, and the penis elongated by traction before 
the manoeuvre is repeated ; further assistance may be obtained, if 
necessary, during the latter part of the introduction, by gently 
pressing against the convexity of the instrument in front of the anus 
or by introducing a finger into the rectum, ascertaining the exact 
position of the point and guiding it forwards and upwards against 
the posterior surface of the symphysis ; the passage of the extremity 
over the uvula vesicas is often indicated by nausea or a slight tremor 
on the part of the patient, and its entrance into the bladder by a 
flow of urine. 

Let us review these several steps, and notice the ■ chief natural 
obstacles which are to be avoided. The first is the lacuna magna 
situated upon the upper surface of the urethra; this is to be shunned 



INTRODUCTION OF THE CATHETER. 287 

by directing the point towards the lower surface during the first 
two inches of its passage. The second is the symphysis pubis, 
against which the extremity of the instrument will impinge, if the 
abdomen be distended and the handle be held in the median line ; 
hence the direction to hold the shaft parallel to the fold of the thigh, 
and not to bring it to the median line or elevate it until the point 
has penetrated beneath .the symphysis. The third is the sinus of 
the bulb ; the urethral wall is here very extensible, and is readily 
thrown into a fold upon which the point of the instrument catches 
instead of passing through the opening in the triangular ligament 
into the membranous portion ; this is less likely to happen if the 
tissues be stretched by traction upon the penis ; and, if it occur, the 
point is to be disengaged by slightly withdrawing it, and afterwards . 
advanced in a direction more towards the upper surface of the canal. 
It is to be observed that this is the only stage of the process in 
which traction upon the penis is desirable; after the point has 
entered the membranous portion, it is positively injurious. Again, 
hypertrophy of the prostate or abnormal development of the uvula 
vesicas may oppose an instrument in the last part of its passage ; 
this is to be avoided by depressing the handle and thus elevating 
the point towards the symphysis : in these cases a prostatic catheter 
is often required. 

It is a golden rule in every case of suspected stricture to make 
the first examination with an instrument sufficiently large to distend 
the urethra, whatever history of his previous symptoms may be 
furnished by the patient ; in this manner many sources of error 
already indicated will be avoided. The difference in the impression 
conveyed to the hand of the operator by mere spasmodic contraction 
of the urethra and an organic stricture, is very marked, but can be 
better felt than described. In the former case, the tissues against 
which the point of the instrument impinges evidently preserve their 
natural suppleness, and the obstruction yields to gentle and con- 
tinued pressure ; while in the latter, a firm resilient obstacle is felt, 
which can oe thrust backwards, imparting more or less motion to 
all the surrounding parts ; and if, after a trial of one or more smaller 
instruments, one be found which can be successfully introduced 
within the stricture, it is grasped or "held" by it in a very charac- 
teristic manner. The only phenomenon that at all resembles this, 
is contraction of the voluntary and involuntary muscles which sur- 
round the membranous portion of the urethra, and which are some- 
times called into action, especially in irritable subjects, by the 
presence of a foreign body ; but in this case a full- sized instrument 



288 STRICTURE OF THE URETHRA. 

can still be introduced with but slight difficulty ; and, if allowed to 
remain a short time, the obstruction yields, and the catheter or sound 
is found to be freely movable. Attention to these circumstances 
will facilitate the diagnosis even if the hand be not educated to dis- 
tinguish the palpable difference in the sensations. 

Model Bougies. — Information of value in some cases with regard 
to the size and shape of strictures may be obtained from impressions 
taken upon bougies of wax or other plastic material. Dr. Henry J. 
Bigelow, Surgeon to the Mass. General Hospital, highly recommends 
gutta-percha bougies for this purpose. 1 While house-surgeon of 
this hospital in 1850, I had frequent opportunities of seeing and 
assisting Dr. Bigelow in taking impressions by this method. The 
bougies are first prepared by cutting strips approximating to the 
size desired from a sheet of gutta percha ; they are then slightly 
softened by momentary immersion in hot water, and rolled smooth 
between two boards, when they may be at once hardened again by 
dipping them in cold water. From a number thus prepared, one 
should be selected which will moderately distend the urethra ; it is 
then to be well oiled, and its extremity softened by passing it to and 
fro over the flame of a spirit lamp or candle ; the material will con- 
tinue plastic after it has ceased to be hot, when the bougie is to be 
passed rapidly down to the obstruction, firmly pressed against it for 
a moment, left in place a short time longer to cool, and then slowly 
and gently withdrawn. The tip will be found to bear an impress 
of the anterior surface of the stricture and a portion of the canal 
within it, and will exhibit the position of the obstruction, the size 
and eccentricity of the opening, etc. ; this • may be cut off and pre- 
served for future reference, or for comparison with casts subsequently 
taken. Mr. Thompson 2 objects to this procedure on the ground 
that in a number of instances a portion of the bougie has been left 
in the urethra, and has required an operation for its removal ; " of 
which four cases are reported in the Dublin Medical Gazette, Jan. 24, 
1855." Judging from my own experience, I do not believe this 
accident is liable to occur with due caution on the part of the sur- 
geon. The gutta percha should be pure and freshly prepared, and 
its strength can readily be tested at the time it is used ; when old it 
becomes very friable. I have before me some bougies which I 
made ten years ago, and which are now nearly as brittle as glass 
but I have never seen any approach to an accident, when the mate- 

1 Boston Medical and Surgical Journal, Feb. 7, 1849. 2 Op. cit., p. 188. 



TREATMENT. 289 

rial was fresh and prepared in the manner here directed. I would 
suggest another caution, which is, that the tenacity of gutta percha 
becomes impaired by frequent contact with the urine, and that 
bougies of this substance should not be repeatedly used. It may 
be observed that the " vulcanized rubber," which is now so exten- 
sively employed for various purposes, may be softened over a lamp 
in a similar manner, and would probably make excellent " model 
bougies." Impressions by means of these instruments often afford 
useful and interesting information, especially in cases complicated 
with false passages, but they are not to be regarded as generally 
necessary. 

Strictures of the urethra anterior to the scrotum are often appre- 
ciable from the surface in consequence of the amount of firm deposit 
which surrounds them ; and external as well as internal examination 
is always desirable in order to ascertain the presence of any sinus 
or abscess in the neighborhood of the canal. 



TBEATMENT. 

Constitutional Means. — It is of paramount importance in the 
treatment of stricture not to lose sight of the general condition of 
the system, and particularly of the digestive organs ; indeed, without 
this, local measures, however well directed, will either be greatly 
obstructed in their action, or will utterly fail to produce any good 
result. The necessarily injurious influence of even slight irregu- 
larity of life continued from day to day, may be inferred from a 
consideration of the disastrous effects which may be produced by a 
single excess in wine, exercise, or coitus ; if a few glasses of punch, 
a hearty dinner, or a ride on horseback can occasion urethral con- 
gestion and spasm, and consequent retention of urine, it is reasonable 
to suppose that even moderate indulgence may seriously interfere 
with any attempt to cure the disease. These deductions from theory 
are borne out in daily practice, and it is found to be true as a general 
rule that the more regular the patient's life, the more amenable is 
his case to treatment. 

The constitutional management of stricture must of course vary 
in different cases. Unless the disease be far advanced, it is generally 
sufficient to prescribe such measures as will best promote the health, 
and place the system in the most favorable condition for absorption 
to take place. Another indication of the highest importance is to 
lighten the duty imposed upon the kidneys, and render the urine 

19 



290 STRICTURE OF THE URETHRA. 

bland and unirritating to the inflamed surfaces over which it passes , 
and this is to be chiefly accomplished by regulating the character 
and quantity of food, and favoring depuration of the blood through 
other channels, as the skin, bowels, and lungs. The diet should be 
simple but sufficiently nourishing; alcoholic stimulants, highly 
seasoned food, cheese, cabbage, salt meats, strong coffee, and all 
articles which tend to load the urine should be avoided, as also 
tobacco — unless in great moderation ; the bowels should be opened 
daily, if necessary, by gentle laxatives, but violent purges are to be 
avoided. The skin should be stimulated by frequent bathing and 
friction ; when there is much irritability of the urethra, the hot hip- 
bath will be found very beneficial; no more exercise should be 
taken than is sufficient to maintain the appqf ite and strength ; and, 
in general, the patient should lead a quiet and regular life. When 
the urine is alkaline, or contains an undue quantity of lateritious 
deposit, great benefit will be derived from the compounds of potash 
and soda with the vegetable acids, as the citrate and acetate of potash, 
the tartrate of soda and potash, etc. Mr. Thompson recommends 
benzoic acid in these cases. 

In the more severe cases of stricture, especially when the patient 
has suffered from one or more attacks of retention of urine, it is 
desirable to confine him to the house or even to the bed for a week 
or fortnight before commencing direct treatment ; and this course 
becomes necessary when it is proposed to resort to external or inter- 
nal incisions, or to rapid dilatation. 

Some advantage might perhaps be derived from the administration 
of iodide of potassium, which, when given in the thirtieth dilution, 
is capable, according to the statement of some homoeopaths, of curing 
all cases of stricture (!) ; but, so far as I am aware, there is at present 
no reliable evidence that this or any other article of the Materia 
Medica can effect absorption of the adventitious deposit of urethral 
obstructions. 1 

Probably no class of affections has more thoroughly taxed the 
ingenuity of surgeons to discover some speedy and effectual method 
of cure, than have strictures ; and a volume, the size of the present 
one, might be filled with the different operative procedures which 
have 1 been proposed for this purpose ; but the limits of this chapter 

* Since the above was written, I have noticed a statement by Dr. Thielman, to the 
effect that, he has successfully treated twenty-seven cases of stricture by iodide of 
potassium alone in doses of two and a half grains three times a day. New Jersey 
Medical and Surgical Reporter, Jan. 1858, from the Medical Gazette of Russia, 1857. 
This statement requires confirmation. 



DILATATION. 291 

require that I should confine myself to the strictly practical, and 
dilate on those methods only which have stood the test of time, and 
which are generally adopted by the soundest surgeons of the present 
day; but few of the many which, though extolled for a short 
period, have soon sunk into forgetfulness, will receive even a passing 
notice. 

Dilatation. — From a very early period in the history of surgery 
dilatation has held, as it continues to hold, the first place in the 
treatment of stricture. Unassisted by other measures, it is able to 
overcome the larger number of urethral contractions; and, when 
other methods are employed, it is still required to complete and 
give permanency to the cure. Dilatation may therefore be regarded 
. as an essential element of all treatment ; and the greater the impor- 
tance attached to it by the surgeon, the more satisfactory will be the 
results attained in practice. The reason of this pre-eminence is to 
be found in the fact that dilatation accomplishes more perfectly than 
any other method the removal of the fibro-plastic material which 
constitutes stricture. Numerous explanations have been given of 
its mode of action, but the one now generally received, and which 
is unquestionably correct, is, that, so far as it effects any perma- 
nently good result, it acts by promoting absorption. The presence 
of a bougie within a stricture may mechanically dilate its walls, but 
sooner or later after the withdrawal of the instrument, the plastic 
material again contracts; and all the phenomena attendant upon 
dilatation show that it accomplishes something more, than this, and 
that, like pressure upon external tumors, it possesses the power of 
producing absorption of inflammatory deposits. At an early period 
of the existence of stricture, before its constituent elements have 
become firmly organized, there is reason to believe that they may 
be entirely removed by the treatment now under consideration ; at 
a later stage, a portion only can be thus dissipated, and it is in these 
cases' that we are forced to be content with palliating the evil by 
mechanically enlarging the canal from time to time, or, when the 
contraction is so firm as not to admit of this, by incising or rup- 
turing the obstruction and afterwards stretching the recent fibrinous 
deposit which forms between the edges of the wound. 

The instrument employed in dilatation, whether a catheter, sound, 
or bougie, is in most instances a matter of but small importance, as 
may be inferred from the great diversity in the preferences of 
different surgeons, though the weight of authority is probably in 
F avor of a metallic instrument. Every operator will generally use 



292 STKICTURE OF THE URETHRA. 

that one most successfully to which he is most accustomed ; but 
there are certain cases in which each possesses peculiar advantages. 
Thus the unyielding material of metallic instruments gives them 
the preference in firm, indurated strictures which are liable to 
indent the softer substance of flexible bougies; moreover, being 
inflexible, they are entirely under the control of the operator, and 
can be guided with precision in any desired direction ; in all cases 
complicated with false passages they should undoubtedly be pre- 
ferred. Their disadvantages are a liability in unskilful hands of 
doing injury to the urethral walls ; the terror which they inspire in 
timid patients, and their inability to adapt themselves to the flexures 
of the canal, whence their introduction is attended with somewhat 
more uneasiness than flexible bougies. Granting, however, the 
possession of that amount of anatomical knowledge, patience, and 
delicacy of touch, which alone can justify any one in performing 
catheterism, there is no serious objection to their employment ; but 
flexible bougies are far safer in the hands of those not endowed with 
these necessary qualifications. 

Especially in the first examination of any case, no instrument 
equals in value the ordinary silver catheter ; its entrance into the 
bladder is surely indicated by the flow of urine through the tube, 
and its blunt point accurately defines the position of any obstruction. 
Sounds or catheters when used for the purpose of dilatation, may 
be slightly conical at the extremity, as this form corresponds to the 
opening of most strictures and facilitates the introduction of instru- 
ments. In a few rare cases of tortuous and contracted strictures it 
is impossible to pass any instrument except a filiform bougie, which 
is preferably made of whalebone or of gum-elastic. 

The same method should be followed in performing dilatation as 
in ordinary catheterism. If the first instrument employed will not 
enter the obstruction, a second and smaller one must be tried ; the 
dimensions of the stream of urine indicating by approximation the 
actual size required. All attempts to penetrate the narrowed channel 
should be made with the utmost gentleness, and any sudden thrust- 
ing of the instrument especially avoided ; force is only admissible 
when the point is felt to be "held," thereby indicating that it is 
already engaged in the passage, and even then pressure must be 
steady, only very gradually increased, and always moderate. False 
passages are usually found below or at the sides of the urethra ■ 
hence, if there be any reason to suspect their presence, the extremitv 
of the catheter should be carefully guided along the upper surface. 
It often happens, however, that the orifice of the stricture is eccen- 



DILATATION. 2^3 

trie, being above or below, or to one side of the centre of the canal ; 
if therefore previous attempts have proved unsuccessful, the direction 
of the instrument may be varied ; or, if a bougie be used, it may 
be twisted on its axis at the same time that it is gently pressed for- 
wards. Assistance is sometimes afforded, especially in strictures of 
the spongy and bulbous portions, by passing the disengaged hand 
down to the seat of the obstruction and exercising a certain degree 
of pressure externally. In cases of extreme difficulty, Mr. Thomp- 
son 1 recommends that the urethra should first be freely injected with 
olive oil, which is to be retained by compression of the meatus 
while a small instrument is passed ; he believes that thus the stric- 
ture is not only thoroughly lubricated, but also somewhat dilated 
by the mechanical pressure of the fluid, and states that this method 
has proved of very decided advantage in his hands. 

The length of time that the instrument should be retained will 
depend somewhat upon the sensitiveness of the canal ; although here 
I think a distinction should be made between sensibility attendant 
upon inflammation and that which is chiefly nervous, the former 
will be aggravated by the prolonged contact of a foreign body, the ' 
latter diminished; as photophobia is in many cases relieved by 
gradually accustoming the eye to light, so there is no more effectual 
remedy for nervous irritability of the urethra than the introduction 
and temporary retention of a catheter, and attention to the circum- 
stances of the case will enable the surgeon to apply these principles 
to practice. As a general rule five minutes is sufficiently long for 
the first session, and the period may gradually be extended at sub- 
sequent visits to half an hour. 

The phenomena following the passage of an instrument through 
a stricture have been carefully studied by Mr. Thompson, and are 
both highly interesting and instructive. At the first succeeding 
act of micturition, the stream of urine is found to be increased in 
size ; in the course of a few hours it diminishes, and is even smaller 
than before the introduction of the instrument ; finally, after a day 
or two, it is permanently enlarged. Mr. Thompson attributes the 
first mentioned effect to mechanical dilatation ; the second to reactive 
congestion and spasm ; and the third to the subsidence of the latter, 
and to the removal by absorption of a portion of the organic deposit. 
The practical deductions from these observations are : that an instru- 
ment should not be inserted with such force, nor retained so long, 
as to excite decided inflammatory action; and that catheterism 

1 Op. cit., p. 179. 



294 STEICTUEE OF THE UEETHRA. 

should not be repeated until all irritation produced by previous 
applications has disappeared. 1 

An interval of from two to five days between the applications 
is usually sufficient. At the second visit, the instrument first em- 
ployed may be introduced for a moment, then withdrawn, and the 
next larger size inserted. With very irritable strictures, it is often 
advantageous to proceed even more slowly than the ordinary catheter 
scale admits ; that is, by instruments intermediate in size between 
the numbers upon this scale, such as may be found in most collections 
of bougies. For this reason, the more minute division 'of the French 
scale, which is divided into thirds of a millimetre, is an improvement 
upon the English. 

Thus, by a gradual advance, the passage may be enlarged to a 
calibre corresponding with that of the external meatus, and although 
this degree of dilatation is usually sufficient, yet it is sometimes 
desirable to exceed it and to restore the constricted portion of the 
canal to its original diameter, which can only be done after incision 
of the unyielding meatus. This is especially advisable in strictures 
attended by frequent attacks of retention, and which speedily relapse 
after the cessation of treatment, since it is found that free dilatation 
with instruments carried in some instances as high as No. 15 or 16, 
renders the cure much more permanent. Under no circumstances 
should catheterism be at once abandoned so soon as the stricture is 
dilated to the desired extent, whatever that may be ; but instruments 
should be passed at gradually increasing intervals, as, for instance, 
once a week for a short period, then once a fortnight, and so on, 
until several months have elapsed. 

Some strictures prove impermeable on the first trial, and if, after 
continuing the attempt as long as appears justifiable, success be not 
attained, it is better to defer farther efforts until a subsequent visit. 
Attention has already been called to the fact that those surgeons 
who, like Dr. Phillips, have acquired a reputation for their power 
in overcoming apparently impassable strictures, attain success as 
much by their repeated trials and dogged perseverance as by their 
skill. In cases of " impermeable stricture," especially when attended 
with much sensibility and spasmodic contraction of the urethra, 
great advantage will be derived from placing the patient under the 
influence of an anaesthetic, but the condition of insensibility must 
not be abused to employ more force than would, under other circum- 
stances, be thought justifiable. Pressure against the face of a stricture, 

1 Thompson, op. cit., p. 210 et. seq. 



CONTINUOUS DILATATION. 295 

steadily continued for ten or fifteen minutes, and repeated if neces- 
sary on several occasions, will sometimes prove successful, after an 
attempt to insinuate the instrument within the passage has failed ; 
but care should be taken that its point is really directed against the 
contraction and not upon the urethral wall in the neighborhood. 
Excepting those cases in which retention of urine demands imme- 
diate evacuation of the bladder, and where no opportunity is afforded 
for making repeated and persevering attempts at catheterism, the 
surgeon will meet with but few strictures which he cannot ultimately 
succeed in overcoming by the dilating process. 

Continuous Dilatation} — A more expeditious mode of dilating 
stricture is by the method known as "continuous dilatation," in 
which the catheter is retained for a considerable length of time, 
generally for several days in succession. In the course of twenty- 
four or forty-eight hours, a purulent discharge appears, proceeding 
from the abraded or ulcerated mucous membrane at the seat of the 
obstruction, and the passage is rapidly enlarged. 

This method is employed by some surgeons in all cases of passa- 
ble stricture, but such practice is not commendable, since it is less 
effective than gradual dilatation in removing the organized material 
constituting the obstruction ; is more likely to be attended by un- 
toward symptoms ; and is followed by a strong tendency to recon- 
traction. But although continuous dilatation should be rejected as 
an exclusive method of treatment, it is extremely valuable, under 
certain circumstances, as a temporary resort, and as preparatory to 
the intermittent use of instruments. It is advisable: 1st, when time 
is of great importance, as with persons from a distance or with sea- 
faring men, for whom much may be accomplished in a few days, 
and the after-treatment be left to the patient, instructed in passing 
an instrument upon himself; 2d, when, in narrow strictures or in 
those complicated with false passages, great difficulty has been expe- 
rienced in introducing the catheter, and fears are entertained that it 
cannot be reinserted if once withdrawn ; and 3d, when it is found 
impossible to repeat catheterism except at long intervals, either in 
consequence of extreme irritability of the urethra, or of rigors fol • 
lowing each application. The latter often attend the first succeeding 
act of micturition, and appear to be due to the contact of urine with 
the abraded mucous membrane. 

In either of the above cases if a catheter can be introduced 
through the stricture, it may be retained in place by tapes passed 

1 "Dilatation permanente" of the French. 



296 STRICTURE OF THE URETHRA. 

through its rings and attached before and behind to a bandage 
around the abdomen; its point should not be allowed to project into 
the bladder sufficiently to injure the vesical coats; its external 
orifice should be connected with a urinal or fitted with a plug which 
can be removed whenever a desire is felt to urinate, and the patient 
should be confined to the bed. Considerable pain and other un- 
pleasant symptoms are often experienced within a few hours, but 
unless these be severe the catheter should not be withdrawn, as the 
object in view would be thereby defeated. The strength should be 
supported by nutritious diet or even stimulants ; pain may be allevi- 
ated by opiates given by the mouth, or, preferably, in the form of 
suppositories, and rigors may be met by hot applications to the sur- 
face, and opium internally. The occurrence of fits of shivering for 
the first time after the catheter has remained in for several hours, 
or the appearance of considerable blood in the urine, are indications 
that the instrument should be at once withdrawn, and treatment 
suspended for a few days. 1 

In most cases, the catheter may be retained for twenty-four to 
forty-eight hours, not longer, lest it become incrusted with calculous 
deposit, or ulceration of the urethral walls be induced ; the patient 
is then allowed to rest for a day or two, and a larger one inserted. 
After several such applications, the urethra will generally be suffi- 
ciently dilated to admit a No. 8 or 10 instrument without difficulty, 
but the treatment must not be allowed to rest here; there still 
remains a strong tendency to contraction, which must be overcome 
by frequent catheterism repeated at first every day or two, and sub- 
sequently at increasing intervals, as after gradual dilatation ; by this 
means only can it be hoped to maintain the ground already gained, 
and to effect the removal of the contractile material which induces 
relapse. 

Rapid Dilatation. — Continuous dilatation above described, is also 
in a measure rapid, but it accomplishes its object indirectly, while 
the methods we are now briefly to consider aim directly at the speedy 
enlargement of the passage. 

Eapid dilatation may be effected by means of conical sounds or 
bougies, the small extremity of which is introduced within the 
stricture and advanced by gentle but steadily continued pressure 
until the shaft, which is several sizes larger than the point, is fairlv 
inserted; the instrument may then be allowed to remain for several 
hours, and a larger one substituted for it. 

1 Thompson, op. cit. , p. 193. 



RAPID DILATATION. 



297 




Several instruments invented for rapid di- Fi s- 19 * 

latation are constructed upon the common 
principle of a series of tubes varying in di- 
ameter, which slide one upon another. In 
the instrument of Mr. Thomas Wakley, a 
No. 1 silver catheter is employed as a guide, 
which is first introduced into the bladder, 
and the tubes passed in succession over it. 
When the desired degree of dilatation has 
been accomplished at any one session, a 
flexible catheter may be inserted in place 
of the largest silver tube which has been 
used, and, the conductor having been with- 
drawn, be retained until the next visit. 
From the strong testimony adduced by Mr. 
Wakley in favor of his method, it would 
appear to be well worthy a trial in some 
cases. 

In the instrument invented by Dr. Buchanan, of Glasgow, the 
sliding tubes and a central conducting wire are united into a "com- 
pound catheter" (Fig. 19), which is first introduced as far as the 
obstruction, when the guide is pushed on through it together with 
as many of the tubes as will effect the desired degree of dilatation. 
It is stated by Mr. Thompson that this instrument has been claimed 
as a modern invention in London within the last few years, and such 
has also been the case in this neighborhood. 

M. Maisonneuve has invented an ingenious method of treatment 
which he calls "cathe'terisme a la suite." A very slender and flexible 
bougie, well adapted to pass the longest and most tortuous stric- 
tures, serves as a pioneer; when once this is introduced, various 
instruments may be screwed to its external extremity and passed 
through the obstruction following the bougie as a guide, the flexi- 
bility of the latter permitting it to be coiled up in the bladder 
as fast as it enters this cavity. If, for instance, it is desired to 
draw off the urine, a hollow bougie with an eye upon its side is 
screwed to the conductor and passed into the bladder, while larger 
bougies or a urethrotome may be attached for the purposes of 
dilatation or internal incision. 1 The guide is left in the urethra 
from one visit to another, so that there is no necessity for repeated 

1 A catheter armed at the point with a bougie was employed for the relief of reten- 
tion of urine by Dr. Physick, of Philadelphia, as early as 1796. Thompson's probe- 
pointed catheter is a modification of the same instrument. 



298 



STRICTURE OF THE URETHRA.. 



Fig. 20. 



introduction. Although this method is beautiful in theory, it 
cannot be said to have been fully tested in practice. It would 
appear probable that it may occasionally prove of value, especially 
in narrow strictures complicated with retention, when 
it is impossible to introduce any instrument but a fili- 
form, flexible bougie, too small to draw off the urine ; 
and when otherwise it would be necessary to puncture 
the bladder. 

Expansion. — Attempts have been made to expand 
strictures : — 

1. By instruments made of some porous material 
which will dilate when moistened by the urethral se- 
cretions. Thus, bougies of "flexible ivory," or ivory 
deprived of its calcareous matter by immersion in a 
weak acid, have been used for this purpose by the 
French ; bougies of slippery elm by Dr. Wm. A. 
McDowell, 1 formerly of Downesville, and Prof. Nathan 
Smith, of Baltimore; and compressed sponge by Dr. 
Alquie, 2 of Montpelie", and Dr. Batchelder, 3 of this 
city. These attempts have not as yet, so far as I am 
aware, attained any satisfactory result, and in a trial 
of bougies of flexible ivory made by Eicord, the por- 
tion of the instrument which was introduced beyond 
the stricture dilated to such an extent that it was with- 
drawn with great difficulty, and the necessity of exter- 
nal incision became imminent. 

2. By sacs of oiled silk, gold-beater's skin, or other 
impervious material, which may be introduced through 

A. Filiform bou- the stricture by means of a stylet, and afterwards di- 
gie. B. Flexible l a ted with air or fluid, as proposed by Ducamp, and 

catheter with an . . 

opening upon the ^. James Arnott.* 

side, screwed to 3. By various instruments with expanding blades, 
the former. rp^ em pi oym ent of all these methods has been 

chiefly confined to their inventors, and cannot be recommended as 
superior or even equal to other modes of dilatation. 

Rupture. — Under the name of the " immediate plan," the sudden 
and forcible dilatation of strictures has been proposed by Perreve, 

1 Gross, op. cit., p. 778. 

2 Gazette de3 Hopitaux, 24 Juin, 1854, p. 300. 
8 New York Journal of Medicine, May, 1859. 
* Stricture of the Urethra, London, 1819. 



RUPTURE. 



299 



Mr. Holt, and others. With the very strong testimony adduced in 
favor of this method, I am happy to reverse the judgment expressed 
in the first edition of this work, and to state my belief that, in this 
instance as in many others, experience proves the value of a mode 
of treatment which at first has been rejected upon theoretical 
grounds. 



Fig. 21. 




J 



G.TIEMANN-Co. 



CsJI^B: 



aC^at 



<3^Stt= 



Mr. Holt's instrument. 



Mr. Holt's instrument, which is decidedly the best, consists of a 
sound (equalling in diameter No. 3 of the ordinary catheter scale), 
which is split nearly to the extremity and encloses a central wire, the 



Fig. 22. 




a' 



Mr. Smyly's modification of Mr. Holt's instrument. 

(a) The dilator closed. 

(6) The branches slightly opened to show the wire guide in the position of the stilette in 
Holt's instrument. The dilator (e) is not quite pushed to the end. 
(c) The guide of silver wire, 
(rf) No. 1 catheter, either of silver or gum elastic, to which any curvature may be given 



300 STRICTURE OF THE URETHRA. 

latter serving as a guide to a number of tubes, which may be passed 
along it with the effect of forcibly separating the blades and rup- 
turing the stricture. 

Mr. P. C. Smyly has modified and improved Mr. Holt's instrument 
by making the central wire (terminated by a small silver button) 
independent of the rest of the instrument, so that it may alone be 
introduced through a stricture of very small calibre, and serve 
both as a guide to a No. 1 catheter for the evacuation of the 
urine in cases of retention, and to the dilator for the rupture of the 
contraction. 

At a discussion before the Eoyal Medical and Chirurgical Society, 
April 14, 1863, Mr. Holt stated that he had now operated in hospital 
and private practice, upon more than 250 cases, without any com- 
plication of either infiltration of urine, abscess, swelled testicle, or 
inconvenience of any kind, further than the occasional supervention 
of a rigor, or mild attack of urethral fever; also that the operation 
did not require either the previous or after retention of a catheter 
in the bladder, that the administration of an anaesthetic was rarely 
necessary, that the patient was not confined to the house longer 
than the afternoon in which the operation was performed, and that 
ihe pain was of the most trifling description. If only half of these 
claims should prove true, this method would be a most valuable 
one in the treatment of stricture, and it is no more than justice to 
Mr. Holt to say that it has received the highest encomiums from 
others than himself. 1 

As these pages are passing through the press, the second edition 
of Mr. Holt's work (On the Immediate Treatment of Stricture of 
the Urethra, by the Employment of the "Stricture Dilator") has 
appeared, giving an account of a very great improvement in the 
construction of the instrument, which attains the same end as Mr. 
Smyly's modification. The directing rod is made hollow, with an 
opening at the back of the curve jof the dilator, so that the escape 
of urine will indicate when the instrument has entered the bladder, 
and relief is afforded in cases of retention ; again, an alteration in 
the construction of the handle renders it impossible for the tube to 
escape from between the blades of the dilator. 

1 See "A Retrospect of some cases of Stricture of the Urethra," by J. Smyly, 
A.B., Dublin Quarterly Jour, of Med. Sci., Nov., 1862; "On the Treatment of Stric- 
ture by the Immediate Plan," by Rawdon Macnamara, M.R.I.A., ibid.; "On the 
Treatment of Stricture of the Urethra by the More Immediate Plan," by Philip 
Crampton Smyly, MX., same journal for Feb., 1863 ; and the report of the Medical 
and Chirurgical Society's session, April 14, 1863, in the Medical Times and Gaz., 
May 2, 1863. 



CAUSTICS. 301 

I have also had the opportunity of testing Mr. Holt's method in 
three cases of stricture with the most satisfactory results, and, so far 
as I can judge from this small experience, I am led to indulge the 
most favorable opinion of its value. 

Mr. Holt recommends, after the rupture of the stricture, that 
the urine should be drawn off by means of a full-sized catheter, 
and the patient be sent to bed for the first day and night, during 
which he should take, every four hours, a mixture containing 
m each dose two grains of quinine and ten minims of the tincture 
of opium. The daily use of the catheter should subsequently be 
continued as after internal urethrotomy. 

Caustics. — Caustics, at times extolled as the most efficient means 
of treating stricture, and at other times decried as useless and in the 
highest degree dangerous, have succeeded in maintaining a favor- 
able position in the general estimation of the profession ; not, how- 
ever, as an exclusive mode of practice, but as an adjunct to dilatation. 
It should be observed that these two methods are inseparable, even 
when not, as is usually the case, intentionally combined ; since the 
instruments employed in the application of caustics must necessarily 
distend the canal like bougies or sounds. This fact renders it some- 
what difficult, in any case of successful treatment in which these 
remedies have been employed, to determine what proportion of the 
credit is due to them and what to dilatation ; but the general im- 
pression upon the minds of those who have given them a fair trial 
is sufficient to warrant the favorable opinion above expressed ; which 
is founded not only upon the testimony of the warm advocates of 
this mode of treatment, Messrs. Whately and Wade, but also upon 
that of Mr. Henry Smith, Mr. Thompson, several personal friends in 
this city, in whose judgment I place the highest confidence, and my 
own experience. 

It is necessary, however, to, define with greater minuteness the 
position which caustics are believed to hold ; and this may be done 
i n the following terms : — 

1. They are not to be used as escharotics for the purpose of de- 
stroying the plastic material which constitutes strictures ; hence of 
these agents the milder forms should be preferred, or the stronger 
caustics should be employed in small quantities only. 

2. They are especially adapted to cases of irritable stricture, in 
which they diminish sensibility and spasm, and permit of the freer 
use of dilatation ; 



302 STRICTURE OF THE URETHRA. 

3. To cases in which there is a strong disposition to hemorrhage, 
in which they control the vascularity of the part ; and 

4. To some cases of tough and fibrous contractions, in which they 
appear to assist dilatation by exciting absorption. 

The chief caustics employed in the treatment of stricture are 
nitrate of silver and caustic potash ; to the former of which my own 
experience has for the most part been confined. The mode of appli- 
cation is exceedingly simple. A depression is to be made in the 
extremity of a wax bougie, in which a small fragment of the solid 
nitrate is deposited, and the adjacent substance pressed around it, so 
as partially to overlap it and retain it in place. The instrument is 
then to be oiled, passed rapidly down to the anterior face of the 
stricture, or, if possible, within it, retained in position from one to 
two minutes, and then withdrawn. In the course of three or four 
days, a plug of coagulated mucus and epithelium may often be de- 
tected in the urine, the pain of micturition is lessened, and, on farther 
trial of dilatation — which should never be omitted — the sensibility 
of the canal is found to be much diminished. If the passage be of 
sufficient size, caustic may be applied to the interior of the stricture 
by means of Lallemand's porte-caustique, or, better still, with the in- 
strument devised by Leroy D'Etiolles, which is free from an objec- 
tion to which the former is liable, viz., that of being forcibly retained 
by the spasmodic action excited by the application. 

The use of potassa fusa in the treatment of urethral stricture was 
first adopted and recommended by Mr. Whately, 1 who employed a 
very small quantity, not exceeding one-twelfth of a grain in weight, 
nor in size " a common pin's head," and only in case a bougie at 
least a size larger than the finest could be passed into the bladder ; 
that retention, if caused by the treatment, might be relieved by the 
passage of a catheter. A freer use of potassa fusa in impermeable 
as well as permeable stricture has since been advocated by Mr. 
Wade, 2 whose views, founded upon^n experience of thirty years, 
and supported by the details of a large number of successful cases, 
entitle this agent to a more extended trial than has yet been given 
it ; for, although occasionally mentioned with approval by various 
writers, and among others by our countryman, Dr. Gross, 3 it has not 
generally met with much favor, and has been regarded as too power- 
ful and unsafe to be experimented with. Mr. Wade not only believes 
it as harmless as nitrate of silver, when used with proper caution 

1 An Improved Method of Treating Strictures in the Urethra. London, 1804. 

2 Stricture of the Urethra, 4th edition, London, 1860, pp. 92-155. 
* Op. cit., p. 788. 



CAUSTICS. 



303 



Fig. 23. 




"hut that it possesses powers far superior; that it is especially indi- 
cated in irritable and unyielding strictures, which of late years have 
been treated by incision ; and that it is calculated 
to supplant urethrotomy altogether, or to confine 
it to a very few exceptional cases. The following 
extracts from his work will still farther explain 
his views, and his mode of practice : — 

"The caustic potash may be advantageously 
applied to strictures for two purposes: one to 
allay irritation, the other to destroy the thickened 
tissue which forms the obstruction. When used 
in the minute quantity employed by Mr. Whately, 
I believe its action to be simply that of allaying 
irritation, as, when mixed with lard and oil, com- 
bined with the mucus of the urethra, it can scarcely 
have any effect beyond a mild solution of caustic, 
which most probably causes a more healthy state 
of the lining membrane of the stricture. Before 
using the potash, a bougie should be passed down 
to the stricture, that its distance from the orifice 
of the urethra may be ascertained. A small piece 
of the caustic, about the size of a common pin's 
head to commence with, should be inserted into 
a hole made in the point of a soft bougie. The 
caustic should be broken just before it is required, 
and the inner or dark part selected, as the outer 
portion is usually less efficient, as it is commonly 
converted into a whitish crust of carbonate of pot- 
ash. Two notches should be made in the armed 
bougie, one marking the exact distance of the 
stricture ; the other, an inch beyond ; so that its 
progress, as it enters the obstruction, may be accu- 
rately observed. The bougie should be moulded 
with the finger round the potassa fusa, so that it may be securely 
fixed ; but to insure the action of the caustic, instead of being below 
the level of the hole, as recommended by Mr. Whately, its points 
should be fairly exposed to enable it to act upon the stricture. 

"The armed bougie should, of course, be well oiled before its 
introduction ; and if the points of the caustic be well covered with 
lard, there need be no fear of its acting before it reaches the stric- 
ture. The bougie should be gently pressed against the stricture for 
a minute or two if impermeable, and then withdrawn. When the 
caustic is applied to permeable obstructions, the bougie should be 



a I 

Leroy D'Etiolles' In- 
strument for "lateral re- 
trograde cauterization." 
(After Thompson.) 



304 STRICTURE OF THE URETHRA. 

passed three or four times over the whole surface of the stricture 
To impermeable strictures, the caustic should be applied with greater 
caution than to such as are permeable ; for should retention of urine 
occur, it will be more easily relieved in the latter than in the former. 
It usually happens that, after one or two applications of the caustic, 
the bougie will be found to enter the obstruction. Before applying 
potassa fusa to impermeable strictures, every precaution should be 
taken to guard against irritation. If convenient, the application 
may be made at bedtime, taking care that the patient passes his 
urine just before; and should he have been subject to rigors or 
retention, it will be best to administer ah opiate injection an hour 
previous to the operation. 

" It appears to me, that the principal superiority of this caustic 
to the nitrate of silver, consists in its more powerful solvent effect 
in removing hard strictures, and that with perfect safety and com- 
paratively with but little pain. Potassa fusa, when used for the 
destruction of a stricture, instead of causing a solid slough, appears 
to exert its salutary effects by a process of inflammatory softening 
and dissolution of the thickened tissue forming the obstruction. 

" The periods at which it will be most advisable to repeat the 
application of the potossa fusa must depend upon its effects, and 
the nature of the cases in which it is used. In many old chronic 
strictures, I have used the potash advantageously every second or 
third day ; and in some few instances, under peculiar circumstances, 
even oftener. When a stricture has been so far removed by the 
application of potassa fusa as to admit the introduction of a middle- 
sized bougie, it would be best to discontinue the use of the caustic, 
unless there should be difficulty in its subsequent dilatation, when 
an occasional application of the remedy will often be found service- 
able." 

Incisions. — It is often asserted that when any instrument what- 
ever can be passed through a stricture, dilatation is all-sufficient, 
and that it is never necessary to resort to cutting instruments ; but 
although this statement is perhaps applicable to the majority of 
urethral contractions, it is not universally true ; for strictures are 
frequently met with which are so unyielding that dilatation has little 
if any power over them ; or so irritable, that attempts at catheterism 
can only be made at long intervals ; or so resilient, that relapses 
constantly occur. Cases presenting these characteristics constitute 
one class of strictures, in which urethrotomy may often be employed 



INTERNAL DIVISION. 305 

with decided benefit; another class includes certain impassable 
strictures, and those complicated with false passages. 

The question is sometimes asked : " How can incisions effect any- 
permanent good in cases of stricture? None of the adventitious 
deposit is removed by urethrotomy : the lips of the wound must 
eventually unite, and the condition of the parts as before the oper- 
ation be restored : why expect any more benefit than from simple 
incision of the bands of cicatricial tissue following burns, which are 
notoriously incurable by such a procedure?" The comparison is a 
good one, and may serve to show how far the power of urethrotomy 
extends. It is indeed true that unassisted by other measures, it can 
ultimately add nothing to the calibre of the passage, and is, therefore, 
alone incapable of effecting a permanent cure ; but, by giving free 
exit to the urine for the time being, it affords a period of rest ; the 
bladder recovers its tone ; congestion and spasm are relieved ; the 
vascularity of the part is decreased, and spontaneous absorption of 
a portion of the more recent deposit takes place. In this manner, 
great, though temporary, relief is obtained ; but the opportunity is 
afforded for accomplishing still more. Instrumental dilatation may 
now be practised under the most favorable circumstances ; much of 
the adventitious material of the stricture may be removed by thus 
exciting absorption, or, when this is too firmly organized to admit 
of resolution, the recent fibrinous deposit, which, as in other parts 
of the body, takes place between the edges of incisions not united 
by first intention, may be mechanically dilated by the « occasional 
passage of an instrument ; the disease is thus kept in abeyance, and 
comparative comfort afforded. 

Incisions may be internal, or from within; external, or from 
without; in the' former, but little more than the substance of the 
stricture itself is incised ; in the latter, the whole thickness of the 
tissues between the canal and the surface is divided. 

Internal Division. — Internal incisions should rarely be prac- 
tised except for strictures in front of or within the scrotum, or, in 
other words, in the straight portion of the urethra ; when division 
is required for strictures situated in the sub-pubic curve, external 
urethrotomy is generally to be preferred as safer and more satis 
factory in its results. Non-dilatability, irritability, and resiliency 
are the chief conditions which require internal incisions, and these 
are far more frequently met with in strictures of the spongy than 
any other portion of the urethra. They are most marked in contrac- 
tions at the meatus, which can very rarely, if ever, be treated sac- 

20 



306 



STRICTURE OF THE URETHRA. 



Fig. 24. 



cessfully by dilatation ; but they also affect, to a less degree, those 
which are situated within three or four inches of the external ori- 
fice, and sometimes those in the deeper portion of the urethra. 

Internal incisions should also be restricted to cases in which the 
whole thickness of the stricture can be completely divided by a cut 
of moderate depth ; the danger of hemorrhage and of infiltration 
of pus and urine from deep intra-urethral incisions is too great to 
admit of the internal division of thick masses of induration, which 
are more safely treated by external urethrotomy. The distance be- 
tween the point of the blade when fully projected and the 
back of the instrument, should rarely exceed four-tenths 
of an inch, which is the extent of the projection in 
Civiale's urethrotome, and in that of Dr. Peters and Mr. 
Thompson it is even less. 

A great variety of instruments have been proposed for 
internal incisions, some of which are intended to cut from 
before backwards by means of a projecting blade, which 
either has or has not a rod in front of it as a guide; 
while others are designed to be passed through the stric- 
ture and then withdrawn, cutting from behind forwards ; 
they are either straight or curved to correspond with the 
portion of the canal in which they are intended to be 
used. 

Urethrotomy from before backwards without a guide 
should never be performed except in the spongy portion 
of the urethra, and then only to prepare the way for the 
introduction of other instruments. In the deeper portions 
of the urethra it is highly dangerous, since the direction 
of the incision cannot be determined with accuracy, im- 
portant parts may be wounded, or an outlet formed for 
the escape and extravasation of urine. Internal division 
from behind forwards should in all cases be preferred, 
both because it is safer, and because the edges of the cut 
are smoother and less jagged than when made in the oppo- 
site direction. 

Of the many urethrotomes which have been invented, 
Civiale's instrument, figured in the adjoining cut, is pro- 
bably the best, whenever the stricture can be sufficiently 
dilated to admit of its employment. It is designed to 
pass through the stricture, and divide it during its with- 
drawal, after the blade has been made to project. The 
urethrotome, terminal bulb, in which the blade is concealed, equals in 




INTERNAL DIVISION. 307 

• 
diameter a No. 5 catheter, and hence the instrument cannot be used 
when the passage is of less size. 

The bulb at the extremity of the instrument will serve to deter- 
mine the extent of the stricture ; and the incision, implicating the 
floor of the canal, should commence from a quarter to half an inch 
beyond, and be prolonged to an equal distance in front of it, in 
order to insure its complete division. After the operation a full- 
sized catheter should be passed into the bladder (taking care to 
avoid entangling the point in the wound), and be retained for twenty- 
four hours, and dilatation should be practised at gradually increasing 
intervals for a period of several months. 

The great objection to Civiale's and some other urethrotomes 
designed to cut from behind forwards, is that their use presupposes 
a degree of dilatation which, in most instances, would render their 
employment unnecessary, and hence that they are not adapted to the 
very class of cases in which they are most required. This difficulty, 
however, may be obviated by the preliminary employment of either 
of two instruments, admirably adapted for the purpose, the one 
invented by my friend, Dr. Geo. A. Peters, Surgeon of the New 
York Hospital, and the other by Mr. Henry Thompson of London. 

Fig. 25. 




^aE 



C. TIEMANN-CO. 

The urethrotome of Dr. Geo. A. Peters; the blade projecting. 

Dr. Peters's urethrotome consists of a sound supplied with a 
groove in which a blade slides and within which it is concealed, 
except when passing over a projection situated about an inch from 
the extremity. The diameter of the sound does not exceed No. 2J 
or 3 of the ordinary catheter scale, and the instrument may therefore 
be used in strictures of very small calibre. The projection of the 
blade gives the instrument a diameter equalling No. 6| or 7. 

Mr. Thompson's instrument, 1 the dimensions of which are very 
nearly the same, is sufficiently explained by the adjoining cut. 

In neither of these instruments when used alone, is the depth of 

1 The Value of Internal Incisions in the Treatment of Obstinate Strictures of the 
Urethra, London Lancet, Am. ed., Jan., 1860. Many practical suggestions con- 
tained in this section have been derived from this valuable paper, to which the 
reader is referred. 



308 STRICTURE OF THE URETHRA. 

Fig. 26. 



<?T 





Fig. 27. 

Fig. 26. Mr. Thompson's urethrotome. 

Fig. 27. The same with the blade drawn out. 

the incision sufficient to divide the whole extent of the adventitious 
deposit as it more frequently occurs, but they serve to prepare the 
way for the introduction of a larger urethrotome, as Civiale's, which 
will complete the operation. My own experience, which has been 
confined to Dr. Peters's instrument, enables me to recommend it 
very highly. 

Numerous instruments have been invented for the purpose of 
dividing a stricture from before backwards, of which, as already 
mentioned, those only should ever be employed, except in the spongy 
portion of the urethra, which are furnished with a guide to the 
blade. The simplest and, I think, one of the best is a French 
urethrotome (Fig. 28), which consists merely of a sound with a 

Fig. 28. 




• TICMANN— CC> 



projecting elbow, that is blunt except on the margin facing the ex- 
tremity where it presents a cutting edge. It may thus be passed 
through a normal urethra without injury to its walls, but will 
partially cut and partially rupture any obstacle which it meets, the 
small extremity of the instrument having first been insinuated 
within the contraction. 

The urethrotome of Dr. Westmoreland, Atlanta, Geo. (Fig. 29), 
consists of a canula, which is to be passed down to the anterior face 
of the stricture, an exploring wire which is to be passed through it, 
and a blade which slides upon the latter, and divides the con- 
traction. 

Charriere's urethrotome (Fig. 30) is intended for cutting from 
behind forwards as well as from before backwards; in the latter 



INTERNAL DIVISION. 



309 



Fig. 29. 




case, a fine flexible bougie, which may first be introduced through 
any permeable structure however tortuous, serves as a guide to the 
metallic portion of the instrument. Whether so slender a guide as 
this bougie must often be, will 
always be followed, is a question 
which may admit of a doubt, 
and which no personal expe- 
rience with the instrument ena- 
bles me to determine. 

M. Maisonneuve's urethrotome 
consists of a Frere Come's cutting 
instrument, with a filiform bou- 
gie attached to serve as a guide 
as in Charriere's; and highly 
satisfactory results are reported 
from its employment. 

In using either of the above 
mentioned instruments, the im- 
portance of dividing the whole 
thickness of the adventitious de- 
posit should not be forgotten. 
In case the contraction recurs a 
few days after the withdrawal of 
the full-sized catheter introduced 
and retained after the operation, 
the division has not been com- 
plete and the operation should 
be repeated. • 

In the rare cases of impassable 
stricture of the spongy portion of 
the urethra, internal urethrotomy 
may be performed by means of 
the "lancetted catheter," which 
consists of a canula and a blade 
projecting from its extremity. It 
is hardly necessary to observe 
that while using this instrument, 
the penis should not be bent upon 
its point, but that the portions in 
front of and behind the obstruc- 
tion should preserve a straight line, in order to avoid wounding the 
sound urethral walls; and the extremity .of the urethrotome should.. 



310 



STRICTURE OF THE URETHRA. 



Fig. 30. 



Fig. 31. 



B 



D 



'Oi 



if possible, be insinuated, within tlie orifice of the stricture before 

thrusting forward the blade. 

Strictures at or near the meatus 
are peculiarly undilatable, and can 
rarely be successfully treated except 
by incision. When involving the 
meatus they may be divided by a 
curved sharp-pointed bistoury; its 
point protected • by wax during its 
introduction into the canal. (Fig. 
32.) When situated a short distance 
from the external orifice, a probe- 
pointed tenotomy knife, or Civiale's 
concealed bistoury (Fig. 33) may be 
used. After urethrotomy in this por- 
tion of the urethra, the edges of the 
wound exhibit a peculiarly strong 
tendency to reunion and to refor- 
mation of the 4 stricture, and most 
authors speak of the frequent neces- 
sity of repeating the operation. This 
difficulty, however, may be obviated 
in a very simple manner proposed by 
the very able surgeon, Dr. William 
H. Van Buren, as I can testify from 
several cases in my own practice. It 
is merely necessary after the operation 
to insert a tube like the external por- 
tion of a catheter, measuring about 
two inches in length and sufficiently 
large to distend the canal, which is 
to be retained in place by tapes and 
worn for several days. Besides pre- 
venting reunion of the edges of the 
wound, this little instrument obviates 
the pain which is otherwise felt in 

passing water, and its presence is found to occasion but slight 

inconvenience. 



CharriSre's urethro- 
tome, attached to a con- 
ducting bougie, useful 
when the passage is 
much contracted, and 
which may be detached 
and the point/? screwed 
on. 



Lancetted 
catheter. (Af- 
ter Gross.) 



PERINEAL SECTION. 



The external division of stricture by an incision through the 
perineum had,* for several centuries, been known as the "bouton- 



PERINEAL SECTION. 



311 



niere operation," or "perineal section," when, in 1849, Mr. James 
Syme, of Edinburgh, published a work 1 in which he advocated its 
employment exclusively in permeable strictures, through which a 
staff could be passed to serve as a guide, and recommended its 
adoption in a large — and, in the opinion of the mass of the pro- 
fession, an unjustifiable — proportion of urethral contractions. Since 
this time, perineal section upon a guide has been called "Syme's 
operation," or "perineal division," while the names "boutonniere 
operation," "perineal section," and "external urethrotomy,' have 
been restricted to the same operation without a guide. While 



Fig. 32. 




Fig. 33. 
(After Phillips.) 

acknowledging the credit due to Mr. Syme for having carefully 
studied the various steps of this operation, and for the introduction 
of certain improvements in the manner of its performance, it is yet 
difficult to explain on what grounds this innovation in name has 
been made ; for, should Civiale's statement be called in question, 
that a staff was employed by Tolet two centuries ago, it is certain 
that one was frequently used by many operators, both abroad and 
in this country, long before the appearance of Mr. Syme's essay ; 

» Stricture of the Urethra, Edin., 1849, p. 58. 



312 STRICTURE OF THE URETHRA. 

and, waiving the question of priority, the difference in the two 
methods is not sufficient to warrant the proposed distinction, which 
will be ignored in the present volume as it has been by many other 
writers. 1 

Perineal section was adopted in America in the early part of the 
present century, and, for the last forty or fifty years, has been the 
favorite mode of treatment for advanced cases of stricture which 
could not be benefited by other means. 

Dr. H. Gr. Jameson, Surgeon to the Baltimore Hospital, published 
a valuable paper on perineal section in the American Medical Re- 
corder, for 1824, 2 his first successful operation having been performed 
Dec. 2, 1820. Dr. Edward Hartshorne, writing in 1855, speaks of 
perineal section as an " operation which has long been a familiar one 
in Philadelphia." 3 

But in no place in America has there been a greater, nor, it is 
believed, so great an opportunity for studying the performance and 
the results of perineal section as in New York, where this operation, 
for the last forty or fifty years, may be said to have been identified 
with the City Hospital and the surgeons connected with this 
institution.* 

The principles which should determine the surgeon in deciding 
upon perineal section, may be stated as follows : — 

1. It should not be regarded as applicable to any considerable 
proportion of the whole number of strictures, but be reserved for 
exceptional cases, in which milder means have failed. 

2. It should not be employed in a low state of the vital powers, 
nor when extensive disease of the kidneys is present, since, under 
these circumstances, the danger of a fatal result is materially 
increased. 

3. It is advisable in impassable, unyielding, highly irritable or 
resilient strictures, which have proved incurable under a thorough 
and persevering trial of dilatation. The presence of false passages 
is an additional inducement for its performance, since the abnormal 
channel may be cured at the same time that the stricture is relieved. 

1 With reference to the history of external urethrotomy, see an interesting article 
entitled: "Note Historique et Critique siir l'Urdthrotomie Externe ou Section des 
R6tr6cissements de Dehors en Dedans, avant le 18 e Siecle," by Dr. Verneuil, in the 
Archives G6n6rales de M6d., Sept., 1857. 

2 Vol. vii., p. 251. 

8 Review of Thompson on Stricture, Am. Journ. of the Med. Sci., July, 1855. 

4 See two papers by Dr. Lente : Surgical Statistics of New York Hospital, Trans- 
actions of the Am. Med. Association, vol, iv., 1851 ; and Perineal Section for Stric- 
ture of the Urethra, New York Journal of Med., March, 1855. 



PERINEAL SECTION. 313 

4. It is justifiable in some cases of retention of urine dependent 
upon stricture, although in most instances puncture of the bladder 
is to be preferred. 

It is highly desirable that the patient should be prepared for the 
operation by a period of rest, during which he should be confined 
to the house, and, for the most part, to the horizontal posture, his 
secretions be regulated, and his system placed in as favorable a con- 
dition as possible. The perineum should be shaved, and the rectum 
evacuated by an enema. The stricture may present three degrees 
of contraction ; it may be entirely impervious to any instrument ; it 
may admit a fine elastic bougie; it may be possible to introduce a 
grooved sound. In the first case, a catheter of full size is required 
for insertion in the urethra; in the second, the largest possible 
bougie should be passed into the bladder, and a metallic tube, open 
at the extremity, introduced upon it as a guide as far as the obstruc- 
tion ; in the third, the staff employed by Mr. Syme, and which will 
presently be described, is very serviceable, although a similar com- 
bination of a sound and catheter, as in the last case, will answer 
every purpose. 

The patient, having been brought under the influence of an anaes- 
thetic, is placed upon the edge of a table, facing a good light, in the 
position for lithotomy, with the hands bound to the feet by bandages, 
and an assistant supporting each knee. The assistant on his left 
takes charge of the instrument introduced into the urethra, and 
elevates the scrotum out of the way of the operator ; the metallic 
sound or catheter is to be pressed firmly against the obstruction in 
such a manner as to render its extremity somewhat prominent. The 
surgeon, sitting upon a low stool, makes an incision, an inch and a 
half or two inches in length, exactly in the median line of the peri- 
neum, and dividing the tissues by successive strokes of the scalpel, 
opens the urethra upon the extremity of the instrument in front of 
the obstruction ; and here it is to be observed that it is better to ex- 
tend the incision upwards a short distance above the extreme point 
of the catheter, in order to insure the complete division of the 
stricture in this direction. 

The urethra having been opened, the facility of completing the 
operation will depend very much upon whether a guide has been, 
or can be, passed through the contraction. When a bougie or staff 
has been introduced into the bladder at the commencement, the 
division of the stricture upon it is comparatively easy. If this was 
found impossible, the next undertaking is to endeavor to pass an 
instrument through the perineal opening. For this purpose, the 



314 " STRICTURE OF THE URETHRA. 

edges of the incision should be held apart by the fingers of assistants, 
or by means of hooks, or, as proposed by Mr. Avery, a ligature may 
be passed through the urethral mucous membrane on either side, in 
order to afford a clearer field of view, and indicate the position of 
the channel ; and the blood should be removed by constant sponging. 
The most desirable instrument to insert is a grooved director ; if this 
cannot be passed, a fine, flexible bougie, or even a bristle, may be 
tried. Considerable time, patience, and perseverance are required in 
this part of the operation, which often occupies from fifteen to thirty 
minutes, but in most cases, one of the above instruments may even- 
tually be passed. Dr. Gurdon Buck, whose experience in perineal 
section has been extensive, informs me that he has never met with a 
case of failure, but I have known other surgeons to be less fortunate. 
If success be attained, the stricture should be divided from below 
upwards, 1 taking care to include its whole extent, but avoiding 
making the incision so far backwards as unnecessarily to wound the 
deep perineal fascia, whereby the danger of extravasation of urine 
would be increased. Mr. Syme states positively that he has " never 
found it necessary to cut farther back than the bulbous portion, for 
the conveyance of a full-sized instrument into the bladder," and that 
he has never met with a contraction situated posteriorly to this point ; 
but that strictures do exist in the membranous portion, there can be 
no question, although Mr. Syme's statement is probably nearer the 
truth than has sometimes been admitted, since the universal tendency 
has been to assign a seat posterior to the true one, and the oblique 
direction of the perineal fascia which shortens the inferior aspect of 
the membranous region is liable to lead into this error. While, 
therefore, we cannot always expect to avoid opening the deep peri- 
neal fascia, it should be guarded against, if possible, and need not 
frequently occur. 

In some cases, as already intimated, it is found impossible to in- 
troduce any guide whatever through the obstruction. It then 
becomes necessary to search for the urethra posterior to the stric- 
ture, by carefully dividing the tissues in the median line; if a 
fluctuating point be felt, it is probably the dilated urethra, and 
should be opened. It is evident that under these circumstances it 
must often be impossible to trace the contracted and thread-like 
passage through the intervening mass of induration; and much 
time need not be expended in the attempt, if it be not readily 

1 Lest, if made in the opposite direction, the knife, after severing the stricture 
and ceasing to meet with resistance from the mass of induration, unnecessarily 
round the aeeoer tissues. 



PERINEAL SECTION. 315 

found ; since the new channel opened by the knife has, in numerous 
instances, supplied the place of the original canal in a ve-rv satis- 
factory manner. 

A free passage having been opened into the bladder, a full-sized 
catheter should be introduced from the meatus and retained. When 
a bougi$ <&i& sliding tube were passed at the commencement of the 
operation; the latter is readily pushed on to the bladder upon the 
former as a guide. Otherwise some difficulty may be experienced 
in introducing the catheter, the point of which is apt to protrude 
through the perineal opening, and should be guided in the proper 
direction upon a broad director first inserted through the incision. 
After the introduction of the catheter, it should be ascertained if it 
be freely movable in the canal ; if it is felt to be ''held," some fibres 
of the stricture probably remain uncut, and should at once be 
incised ; since their complete division is essential to the success of 
the operation. The catheter is retained by means of a bandage 
around the waist, to which two perineal straps are attached before 
and behind, and the rings of the instrument are connected with the 
latter by threads. The catheter should not be inserted so far that 
its point will press against the mucous membrane of the bladder. 
It is better that its external extremity should not be closed, but be 
connected with a urinal by means of an India-rubber tube, in order 
that the urine may find free exit and less escape through the wound. 
The patient should now be put to bed with the thighs elevated and 
the bedclothes supported by a cradle. Pain may be relieved by 
suppositories of opium, and one should be introduced within the 
anus before the patient leaves the table. Subsequent hemorrhage 
sometimes occurs which it is difficult to arrest by ligature, since the 
thread does not retain a firm hold upon the gristly tissue of the 
stricture ; it may, however, be effectually controlled by inserting a 
piece of compressed sponge between the edges of the wound, or 
firmly plugging it with lint, and bandaging the thighs together. 

The catheter may be allowed to remain two or three days, but 
never more than four, unless in rare instances, when an elastic 
should be substituted for the metallic instrument, or the former 
may be employed from the first. This rule is an important one. 
The danger of prolonged retention lies in the liability to produce 
ulceration of the mucous membrane and subjacent tissues in conse- 
quence of pressure of the instrument. This most frequently occurs 
at two points : one, that portion of the vesical walls which comes in 
contact with the extremity of the catheter; the other, the lower 
surface of the urethra just in advance of the scrotum, at the com- 



316 STRICTURE OF THE URETHRA. 

mencement of the sub-pubic curve, where the penis is upheld by 
the suspensory ligament, and where any straight instrument, like 
the shaft of a catheter, necessarily presses upon the inferior wall of 
the canal. A number of cases illustrating these ill effects have been 
exhibited at various medical associations of this city within a few 
years. In one instance death occurred after the catheter had been 
retained a fortnight, and at the post-mortem examination there was 
found a small but deep ulceration of the bladder, and another, quite 
extensive, of the inferior wall of the urethra in front of the scrotum, 
which was only separated from the surface by the integument. A 
few years since a man, who had been operated upon by perineal 
section in California, and in whom a silver catheter had been 
retained for three weeks, applied to a surgeon of this city for the 
relief of urinary fistula at the angle between the penis and scrotum, 
consequent upon this prolonged retention. The injurious effects of 
such ulceration must be more than local ; in subjects so debilitated 
as patients with stricture often are, they must contribute to the fatal 
result which sometimes ensues. 

The idea sometimes advanced that perineal section is alone suffi- 
cient for the cure of stricture, is, with a few very rare exceptions, 
unquestionably erroneous. Unless catheterism be subsequently 
practised as after other modes of treatment, a relapse is almost sure 
to occur. I have been impressed with this fact in conversing upon 
the operation with different surgeons ; having found that those who 
did not resort to the subsequent passage of instruments were in- 
variably disappointed, while those who did, were as constantly 
pleased with the results. One gentleman, who has performed it in 
nine cases, but who has never followed up the treatment with 
repeated catheterism, tells me that in every instance the disease has 
returned with its original severity. In this city this principle is 
well understood ; dilatation is usually commenced the day following 
the withdrawal of the catheter, and is repeated every twenty -four 
hours, the instrument being left in about half an hour on each occa- 
sion. By the time the perineal wound is healed the patient may be 
taught to pass a catheter upon himself and be dismissed, impressed 
with the importance of continuing it for a long period. When an 
entirely new passage for the urine has been opened, or when the 
stricture was* extensive and firm, directions should be given to pass 
an instrument daily, or every other day, either just before going to 
bed or early in the morning, and leave it in the urethra half an 
nour ; this is to be continued for at least a month, after which period 
catheterism is to be repeated at gradually increasing intervals for a 



PERINEAL SECTION. 



317 



Fig. 34. 



year or more. Unless these directions are faithfully carried out no 
one need expect the slightest permanent benefit from perineal section. 

When perineal section is followed by a fatal 
termination, it is in most cases due to pyaemia ; 
sometimes to urethral fever, attended or not with 
suppression of urine ; and at other times to hos- 
pital gangrene, erysipelas, or urinary infiltration. 
A large proportion of the deaths have occurred 
in hospitals ; in private practice, perineal section 
is found to be a comparatively safe operation, 
especially if confined, as it invariably should be, 
to patients endowed with that amount of vigor 
which is always requisite when the knife is to be 
used. 

In performing "external division," Mr. Syme 
employs a staff with a slender grooved extremity, 
which equals in diameter No. 1 or 2 of the 
catheter scale, and is intended to pass through 
the stricture ; while the main shaft, corresponding 
in size to No. 8, unites abruptly with the former, 
and is arrested at the anterior edge of the stric- 
ture (Fig. 34). Mr. Thompson uses a similar in- 
strument, but "constructed with a hollow through- 
out, by which the urine issuing when it afrives 
at the bladder, the operator knows that the slender 
point is in its proper place, a satisfactory assurance 
when false passages exist, and render the right 
route rather difficult of access." 

Mr. Syme gives the following directions re- 
specting the mode* of performing the operation: 
" The patient should be brought to the edge of 
his bed, and have his limbs supported by two 
assistants, one of them standing on each side. 
A grooved director, slightly curved, and small 
enough to pass readily through the stricture, is 
next introduced, and confided to one of the assistants. The surgeon, 
sitting or kneeling on one knee, now makes an incision in the mid- 
dle line of the perineum or penis, wherever the stricture is seated. 
It should be about an inch or an inch and a half in length, and 
extend through the integuments, together with the subjacent text- 
ures adjacent to the urethra. The operator then taking the handle 
of the director in his left, and the knife, which should be a small 




818 



STRICTURE OF THE URETHRA. 



straight bistoury, in his right hand, feels, with his forefinger guard- 
ing the blade, for the director, and pushes the point into the groove 
behind, or on the bladder side of the stricture (Fig. 34), runs the 



Fig. 35. 




• (After Thompson.) 

knife forwards, so as to divide the whole of the thickened texture 
at the contracted part of the canal, and withdraws the director. 
Finally a No. 7 or 8 silver catheter is introduced into the bladder, 
and retained by a suitable arrangement of tapes, with a plug to pre- 
vent trouble from discharge of urine. 1 The process having been 
thus completed, the patient has merely to remain quietly in bed for 
forty-eight hours, when the catheter should be withdrawn and all 
restraint removed." 

In a clinical lecture, published in the London Lancet (Am. ed.), 
Nov. 1848, Mr. Syme recommends that a catheter through the ure- 
thra should be entirely dispensed with after perineal section, and 
that a short tube through the perineal incision should be substituted 
for it, the better to protect the edges of the wound from contact 
with the urine, which appears to be the exciting cause of the rigors, 
vomiting, rapid pulse, and delirium, which, known as "urethral 
fever," sometimes follow this operation. The short catheter recom- 

1 Mr. Thompson, expressing, as it would appear, Mr. Symc's latest views, says 
vbat the end of the inlying catheter should not be closed. 



CONSEQUENCES OF OPERATIONS UPON STRICTURE. 319 

mended by Mr. Syme, "is about nine inches in length, slightly 
curved in opposite directions at its extremities, and having a couple 
of rings just behind the anterior bend for securing it in its place. 
In addition to the great advantage of affording perfect security, this 
catheter is much less irksome to the patient than the one hitherto 
in use, and cannot, like it, produce any bad effect by pressing upon 
the coats of a contracted bladder." 

Mr. Syme boldly takes the ground that this operation, even when 
not absolutely required by the obstinacy of the case, " is preferable 
to dilatation, as affording relief more speedily, permanently, and 
safely." Holding these views, it is not to be wondered at that his 
operations amount to between one and two hundred, but the freedom 
with which he resorts to perineal section is justly censured by the 
almost unanimous voice of the profession. Eecently, Mr. Syme has 
declined to give the exact number of his cases, or the results. He 
had previously stated that not one of his first seventy operations 
was fatal, but since then several deaths have been known to occur 
in his practice. It may readily be conceded that his success, so far 
as regards mortality, has been unusually great, when it is recollected 
that he performs the operation in cases of a mild character, which 
must for the most part be free from renal disease and general depres- 
sion of the system ; but results thus obtained cannot be taken as an 
indication of the safety of perineal section in advanced cases of 
stricture. Mr. Thompson gives a list of 219 cases by thirty oper- 
ators, among which there were fifteen deaths ; of these he would 
exclude two which were not chargeable to the operation, leaving 
thirteen, or about six per cent. This amount of mortality is suffi- 
cient to forbid perineal section whenever milder, though perhaps 
slower, measures can be successfully employed. 

Consequences of Operations upon Stricture. — Either of the 
modes of treatment now described may be followed by rigors and 
other unpleasant symptoms, which in most cases subside without 
evil result, but which sometimes become serious, aud terminate in 
speedy death. The exciting cause may be simple over-distention 
of the urethra by a larger bougie than has before been used ; abra- 
sion or laceration of its walls by rough handling of the instrument; 
the application of caustic ; or the employment of the knife in in- 
ternal or external incisions. The patient is suddenly seized with a 
chill, vomiting, acceleration of the pulse, and in severe cases with 
great prostration and delirium. These symptoms are most likely 
to ensue upon the first act of micturition succeeding the introduction 



320 STRICTURE OF THE URETHRA. 

of a sound, or the withdrawal of the catheter after urethrotomy ; in 
other words, they follow, and appear to depend upon contact of the 
urine with an abraded surface, through which urea or pus finds 
entrance into the general circulation ; in other instances they are 
apparently due to the shock impressed upon the nervous system 
alone. This combination of symptoms, which is known as "urethral 
fever," is but one form of surgical fever, in the etiology of which 
the absorption of septic matter from the neighborhood of wounds 
plays so important a part, and which has been so ably and thoroughly 
described by Professor Simpson, of Edinburgh. 1 

In most cases, urethral fever terminates in resolution, either with 
or without treatment, in the course of a few hours ; but, especially 
in persons affected with renal disease, and in some instances without 
apparent cause, a typhoid condition with delirium sets in, abscesses 
may form in different parts of the body, and speedy death ensue. 
Complete suppression of the urine is an occasional symptom, and is 
to be regarded as of very serious import. Mr. Thompson relates " a 
case of old standing and narrow stricture, in which death was thus 
caused within fifty-four hours of the passing of an instrument, the 
same that had been habitually employed on at least a hundred 
occasions before, no damage whatever having been inflicted by it 
upon the urethra, as verified by several careful observers on close 
post-mortem examination of the parts. Kigors and vomiting com- 
menced about an hour after the catheterism, and not another ounce 
of urine was secreted from that until death. In this case the kid- 
neys were found congested to an extraordinary degree, and their 
substance was so soft and friable as to give way under gentle 
pressure." 

In a case of perineal section reported by Mr. Syme, "the patient 
suffered nothing from the operation ; had the catheter taken out on 
the second day ; was quite well on the third, and on the fourth was 
lying dressed upon the sofa in the best of spirits. In the afternoon 
of that day, during the act of micturition, he felt an acute pain in 
the perineum, and in walking from one room to another, fell on the 
passage so as to graze his forehead and the outer side of his knee ; 
at the same time he had a violent rigor, followed by quick pulse 
and great pain in the injured parts. As the urine passed freely 
and entirely by the urethra, I expected that these symptoms would 
soon subside, but they continued and went on to suppuration of 
the knee, with destruction of the eyeball, and terminated fatally at 

i Med. Times and Gaz., April 23, 1859. 



CONSEQUENCES OF OPERATIONS UPON STRICTURE. 321 

the end of several weeks. I felt quite unable to account for this 
case until the following one gave me additional light on the subject : 
The patient suffered nothing from the operation, which was of the 
simplest kind, and as he did not complain at all of the catheter, was 
allowed to retain it three days. When it was then removed, he 
expressed perfect comfort, and afterwards wrote to his friends at 
home the most satisfactory account of his progress. At three 
o'clock of the afternoon he passed urine, and felt some pain in doing 
so, which was attended by a slight discharge of blood. Immediately 
afterwards he had a violent rigor, followed by delirium and insensi- 
bility. There was no pulse, no secretion of urine, and he died the 
next day. On examination there was not the slightest trace of 
urinary extravasation, or any other sign of local mischief; but the 
kidneys were gorged with blood to an extreme degree ; and it was 
plain that death had resulted from a sudden shock to the nervous 
system." 1 As already stated, so fatal a result of operations upon the 
urethf a is not frequently met with, but the possibility of its occur- 
rence should always be borne in mind, and lead to the observance 
of due caution. 

In order to conduct the treatment of stricture with safety, the 
general system should be in as favorable a condition as possible ; 
the digestive organs in good order ; and the patient should avoid 
excess both in diet and exercise. It is important also to abstain 
from any operative procedure during the persistence of raw and 
damp weather, or when the patient is fatigued or mentally depressed. 
Let the bladder be evacuated immediately before the introduction 
of the catheter, or the u,se of caustic or the urethrotome, that the 
succeeding act of micturition may be deferred for several hours, 
when the abraded surface of the stricture shall be in a measure pro- 
tected by an effusion of lymph. If rigors occur, they should be 
met by the external application of heat and rubefacients, as bottles 
of hot water to the extremities, sinapisms to the spine and abdomen, 
hot blankets, etc. ; and internally by stimulants and opiates. A full 
dose of the latter should be administered at the outset, and a smaller 
quantity be repeated every few hours, so as to maintain a steady 
narcotic action and lull the irritability of the nervous system. The 
reaction which generally follows should not be treated by active 
depletion; a tendency to general depression soon supervenes, in 
which the vital powers must be supported by stimulants and nour- 
ishment until nature shall have eliminated the toxical materials 
which have found entrance into the system. 

1 London Lancet, Am. ed., Nov. 1858. 
21 



322 STRICTURE OF THE URETHRA. 



TREATMENT OF RETENTION OF URINE. 

Retention of urine, as already stated in this chapter (p. 274). 
chiefly occurs either during the acute stage of gonorrhoea, when it is 
due to inflammation and spasm ; or at some period of organic stric- 
ture, when, in addition to the causes just mentioned, permanent 
contraction of the canal plays a more or less important part in its 
production. It is less frequent in the former case than in the latter, 
and presents less difficulty in the way of treatment. Remedial 
measures must vary somewhat with the condition of the patient, and 
be determined by the judgment of the surgeon. 

When dealing with a subject of full habit, or if there be much 
heat and swelling of the genital organs, or general febrile excite- 
ment of a marked character, it is best to commence with the appli- 
cation of cups or leeches to the perineum. The former are pre- 
ferable, as they abstract blood more rapidly, and about ten Ounces 
of this fluid may be regarded as an average quantity to be drawn. 
If the latter be employed, they should not be less in number than 
ten or twelve. Either with or without this preliminary local deple- 
tion, according to the circumstances of the case, the patient should 
be immersed in a hot bath, the temperature of which should be 
raised to the neighborhood of 102° F., which will probably require 
the addition of hot water after his entrance, since the bath cannot 
at first be borne at so great a degree of heat, and is moreover 
cooled by contact with the body. It is even desirable that a state 
of syncope should be induced, which will greatly favor the reduction 
of spasmodic action. In most cases, the patient will pass his urine 
during immersion ; otherwise, before his removal and while still 
in the water, a medium sized catheter, as, for instance, No. 5, 
should be well warmed and oiled, and an attempt be made to 
introduce it; following the rules already laid down, adhering 
closely to the upper surface of the ' iirethra, stopping for a moment 
whenever an obstruction is met with, and endeavoring to overcome 
it by gentle but continuous pressure: by observing these direc- 
tions, and avoiding the employment of force, no fear need be 
entertained of doing injury to the inflamed and sensitive mucous 
membrane. In the rare instances in which these measures do not 
succeed, the patient should be put to bed, maintained in a state 
of perfect quietude and rest, and other means of an antiphlogistic 
and antispasmodic character adopted. A brisk purgative, as croton 
oil or a full dose of calomel and jalap, may be administered at once, 



TREATMENT OF RETENTION" OF URINE. o23 

and be assisted by the following mixture repeated every two or 
three hours, in order to keep the stomach nauseated and the bowels 
free: — 

R. Antimonii et potassse tart. gr. iv. 

Magnesise sulphatis ^ij. 

Tincturae opii gtt. xl. 

Aquse camphorae ^viij. 
M. 
Dose. — A tablespoonful. 

Excessive catharsis should, however, be avoided : two or three 
free evacuations are sufficient ; and any tendency to too great action 
may be controlled by opiate enemata. Indeed, it is always desirable 
and not inconsistent with the measures just advised, to allay irrita- 
bility and spasm by keeping the system under the influence of opium, 
and this can be accomplished in no better way than by rectal injec- 
tions or suppositories containing laudanum or morphine. If -the 
urine fail to pass in the course of twenty-four hours, an attempt at 
catheterism may be repeated while the patient is again immersed in 
a hot bath, or, better still, after the administration of an anaesthetic. 
It can never be necessary to resort to puncture of the bladder 
when retention of urine is dependent upon inflammatory stricture. 
After relief has been obtained, the catheter should be withdrawn, 
to be reintroduced if found requisite, and a condition of rest should 
be maintained for several days after the urine has regained its normal 
freedom. 

But retention of urine is most frequently observed as a compli- 
cation of organic stricture, when its symptoms are generally more 
alarming and with greater difficulty relieved. The remedial mea- 
sures required vary somewhat from those above given. Unless the 
case has already been subjected to instrumental interference, an 
immediate attempt should be made to introduce a catheter, which 
will be greatly facilitated by placing the patient under the influence 
of ether. First, however, if he have not previously been seen by 
the surgeon, the necessary questions should be asked to learn the 
history of his case ; the degree of contraction of his stricture ; what 
instruments it will admit, or, in default of this, the size of his stream 
of urine, the duration of the retention, etc. etc. The effect of anaes- 
thetics in relaxing the sphincter of the bladder is frequently observed 
when these agents are employed for other purposes, as the stains 
upon the lounge and carpet of a surgeon's office can testify. In 
retention of urine, the contraction of the muscles in the neighbor 
hood of the bladder and urethra is excessive, being not only stimu 



224 



STRICTURE OF THE URETHRA. 



Fie. 36. 



lated by the will, but rendered spasmodic and involuntary bj irri- 
tation of the afferent nerves ; and thus arises one chief obstacle to 

the natural or artificial evacuation of 
the bladder, which can be removed 
far more speedily and effectually by 
the modern application of ether 01 
chloroform, than by hot baths and 
opium, which were formerly solely 
relied on for the purpose. 

The patient having been rendered 
insensible and his muscles thorough- 
ly relaxed, the situation of the stric- 
ture should be ascertained by the 
introduction of a full-sized instru- 
ment; after which gentle and per- 
severing attempts should be made 
to pass the obstruction with a small 
metallic or gum-elastic catheter. If 
not successful with this, a small 
bougie of gum, whalebone, or cat- 
gut may be insinuated within the 
orifice, and allowed to remain a few 
moments, when its withdrawal will 
often be followed by a fine stream 
of urine ; and by repeating the pro- 
cess, if necessary, the entire contents 
of the bladder may be evacuated. 
The same result may sometimes be 
obtained, though with less certainty, 
by pressure against the anterior face 
of the stricture. Again, in strictures 
so contracted that nothing but a fili- 
form instrument will pass, or at least 
none large enough to admit of being 
hollow, the ingenious contrivance of 
" catheterisme a la suite," as em- 
ployed by MM. Maisonneuve and 
Phillips, may be adopted, if the pro- 
per instruments be at hand (see p. 
Thompson's "probe-pointed catheter." 298). 1 Mr. Thompson 2 has also in- 

1 An instance of the successfuPapplication of this method for the relief of reten- 
tion, in the hands of Dr. Phillips, is recorded in Championniere's Journal of Practical 
Medicine and Surgery, for Dec, 1859, p. 552. 2 Op. cit., p. 181. 




TREATMENT OF RETENTION OF URINE. S25 

vented a catheter "combining tubnlar construction with minnte 
size," the extremity of which can be made as small as the finest 
metal probe, and is solid up to abont two and a half inches from 
the point, where the eye is situated ; while the hollow shaft above 
gradually enlarges, first to No. 1, and then nearly to No. 2. A steel 
rod, capable of being screwed in during the introduction of the 
instrument, gives it solidity, and prevents the eye from becoming 
obstructed with mucus or blood. 

After the successful introduction of a catheter in cases of retention 
dependent upon organic stricture, the instrument should be retained 
in place to obviate subsequent trouble. 

Attempts at catheterism may be prolonged to such an extent as 
to irritate and abrade the canal, even if no violence be used. This 
should be avoided ; and if success be not attained after a reasonable 
length of time, other measures should be resorted to. Many cases 
also come under the care of the surgeon, in which instruments have 
already been used to excess by unskilful hands and in no gentle 
manner, and in which the urethral walls have been lacerated or false 
passages opened. Under these circumstances it is best to defer any 
further instrumental interference for a time. The patient should be 
immersed in a hot bath to the verge of syncope and removed to bed. 
and flannels wrung out of laudanum and hot water applied to the 
genital organs and hypogastrium ; but the most reliable remedy at 
this time is opium, with respect to which Sir Benjamin Brodie says: 
" From half a drachm to a drachm of laudanum may be given as a 
clyster in two or three ounces of thin starch. If this should not 
succeed, give opium by the mouth, and repeat the dose, if necessary, 
every hour until the patient can make water. According to my expe- 
rience, the cases in which the stricture does not become relaxed under the 
use of opium, if administered freely, are very rare. The first effect of 
the opium is to diminish the distress which the patient experiences 
from the distention of the bladder. Then the impulse to make 
water becomes less urgent; the paroxysms of straining are less 
severe and less frequent ; and after the patient has been in this state 
of comparative ease for a short time, he begins to void his urine, at 
first in small, but afterwards in larger quantities." The testimony 
of this distinguished surgeon is confirmed by the experience of 
nearly every practitioner ; at the same time it is proper to remark 
that the effect of this drug should be carefully watched, and that it 
should not be pushed to excess. 

The muriated tincture of iron is also a valuable remedy in cases 
of retention, and is much emploj^ed, especially at the New York 



326 STEICTURE OF THE URETHRA. 

Hospital, where it is given in closes of fifteen to twenty drops every 
half hour. Some doubt has been thrown upon the action of this 
agent, from the fact that it is commonly administered in conjunction 
with opium, to which the credit in successful cases has been ascribed. 
I have used it alone in several instances with very favorable results, 
and am disposed to assign it a position second only to opium '*n the 
treatment of retention. 

In every case of this affection, the perineum should be subjected 
to a careful examination, since the obstruction may be caused by an 
abscess or urinary infiltration, the evacuation of which will at once 
afford relief. When such collections form posterior to the triangular 
ligament, the external symptoms are often very obscure. If any 
swelling or doughy hardness can be detected, a free incision should 
at once be made in the median line with a bistoury. This can do 
nd harm, and is likely to be of essential service. Any collection of 
feces in the rectum should be avoided, and the bowels, if not open, 
must be moved by an enema or cathartic. In subjects of a full 
habit, it may sometimes be advisable to draw blood from the peri- 
neum by means of cups or leeches. In the main, however, our reli- 
ance must be placed upon the measures previously referred to ; and, 
if the patient be seen at a sufficiently early period, relief may almost 
always be obtained within twelve or twenty-four hours, either by 
the catheter, or by rest, the hot bath, opium and tincture of the 
chloride of iron. 

No definite rules can be laid down to determine how long, in cases 
of retention of urine, it is safe to defer puncture of the bladder. 
Each case must be decided by itself from a consideration not only 
of the time retention has lasted, but also of the patient's age, strength, 
and general condition, the urgency of his symptoms, the danger of 
rupture of the bladder or urethra, and the risk of injury to his kid- 
neys. Mr. Thompson has the following excellent observations on 
this point : " There are some surgeons who appear to think as long 
as a patient, under the influence of complete retention, presents no 
very urgent constitutional symptoms, it matters little how much his 
bladder be distended, an almost indefinite amount of endurance 
being ascribed to that organ. That this is very great, is not to be 
denied, and the extreme rarity of rupture from this cause, which at 
length takes place, as we have seen, rather by ulceration than by 
mechanical extension of its coats, is invariably referred to as evidence 
in favor of such an opinion. But it is certain that very mischievous 
consequences may result from extraordinary distention (rupture of 
the urethra and extravasation of urine being passed over, as sufti- 



PUNCTURE BY THE RECTUM. 327 

ciently obvious), in its effects upon the kidney, not merely in the 
way of temporary interference with the performance of its function 
as a depurating organ ; but in the lasting injury it fs conceived that 
a few hours of extreme pressure and dilatation may exert on its 
structure. This is so much the more readily susceptible of injury, 
as compared with the bladder, as the secreting organ exceeds the 
muscular reservoir, in complexity, delicacy, and intricacy of con- 
struction. We may not, therefore, continue safely our baths, opium, 
purgation, &c, to the extreme limit of endurance on the part of the 
bladder. Our care for the patient must extend beyond that point, 
and if from his history or condition we have reason to believe in 
the existence of organic renal disease, or only to suspect its presence, 
we shall not be warranted in quietly waiting beyond the time neces- 
sary for the exhibition of appropriate medicinal treatment, and the 
careful use of the catheter, for all of which a very few hours will 
suffice; supposing, it is of course understood, that his powers of 
life at first permitted of the pursuance of that course." 

But while admitting the importance, and even the necessity of • 
resorting to an operation, when such interests are at stake, it must 
not be supposed that the cases in which it is required are numerous. 
It would probably be very near the truth to say, that it is never neces- 
sary when the patient has from the first been under the care of an 
intelligent and competent surgeon; and that retention can always 
be relieved, within a certain period of its commencement, by other 
and milder measures. Unfortunately assistance is not always sought 
from those competent to give it, until this period has been passed 
either in neglect or mismanagement. 

It having been decided that an operation is necessary, four methods 
are at the option of the surgeon : puncture of the bladder by the 
rectum ; opening the urethra through the perineum ; puncture above, 
and puncture through the symphysis pubis. " Forcing the stricture " 
is sometimes enumerated as a fifth method, but is justly discarded 
from modern surgery. Puncture of the bladder through the peri- 
neum is also obsolete. 

Puncture by the Eectum. — This operation is generally admis 
sible, readily performed, comparatively safe, affords the most speedy 
relief, and is consequently the one most frequently adopted. It is 
inadmissible in case the prostate is much enlarged from hypertrophy 
or the presence of a tumor, on account of the danger of wounding 
this body ; also if the bladder be much contracted, since the trocar 
may perforate its anterior as well as posterior wall. Compared with 



328 



STRICTURE OF THE URETHRA. 



opening the urethra in the perineum, it has the disadvantage of not 
aiming at the relief of the stricture as well as of the retention ; but 
this is in a measure compensated for by the facility with which the 
obstruction generally yields to dilatation when once an artificial 
outlet from the bladder has been established, and the urethra is no 
longer irritated by the passage of urine. 

Becto-vesical puncture may be performed with an ordinary curved 
trocar and canula, about eight inches in length, but it is an advan- 
tage to have the former grooved, so as to indicate with certainty by 
the flow of urine when the point has entered the bladder. 



Fig. 37. 



Fig. 38. 








1'ig. 37. Side view of canula and trocar. 1. Eye in the former communicating with the 
groove in the latter. 2. Rings for the purpose of attachment. 3. Channel for the escape of 
urine. 

Fig. 38. Trocar seen on its convex aspect, and showing the groove, which is converted into 
a tube by insertion in the canula. (After Phillips.) 



The patient is to be placed as in the operation for lithotomy, with 
an assistant supporting each extremity. The lower bowel having 
been emptied by an enema, the surgeon introduces his left forefinger, 
well oiled, into the rectum, and feels for the recto- vesical wall just 



PUNCTURE BY THE RECTUM. 



329 



back of the posterior margin of the prostate. A tap upon the hypo- 
gastric regioD with the opposite hand should communicate a sense 
of fluctuation to the point of the finger in the rectum, and this is 
to be regarded as indispensable before proceeding with the oper- 
ation. The canula and trocar are now to be introduced along the 
finger as a guide, and, while an assistant compresses with both hands 
the lower part of the abdomen, the point is directed forwards ex- 
actly in the median line, and, by depressing the handle, made to 
penetrate into the bladder, the accomplishment of which may be 
known by its freedom in this cavity. The canula, carefully kept 
in place during the withdrawal of the trocar, is to be fastened by 
a T bandage, and may be retained until the permeability of the 



Fig. 39. 




Recto-vesical and supra-pubic puncture. (After Phillips.) 

urethra is re-established. The risks of this operation are : wound- 
ing the peritoneum or vesiculae seminales ; consequent peritonitis, 
or inflammation of the appendages and substance of the testicle ; 
persistence of the opening; and abscess between the rectum and 
bladder. In practice, however, these results rarely follow. The 
peritoneum is too high up to be much exposed, and the vesiculae 



330 STRICTURE OF THE URETHRA. 

/ 

seminales may be avoided by adhering closely to the median line. 
The recto- vesical puncture has been known to remain fistulous for 
life, but generally exhibits a strong tendency to close; and the 
formation of abscess is rare. This operation has been a favorite 
one with Mr. Cock, of Guy's Hospital, London, who has performed 
it in twenty-four instances, and has seen it performed in some four 
teen others. He speaks of it in very high terms in the Medico 
Chirurgical Transactions, vol. xxxv., where he also gives a plate of 
a trocar, capable of expansion at its extremity, to avoid its slipping 
from the bladder. 

Opening the Urethra. — An incision into the urethra, which 
may be made to include the stricture, and thus lay the foundation 
for subsequent treatment of the latter, is undoubtedly the most 
advisable operation for the relief of retention, whenever the operator 
possesses the requisite skill and anatomical knowledge, and provided 
the perineum be not too deep, nor its tissues too much altered from 
their normal condition. There are two methods of performing this 
operation. 

In one, which is identical with perineal section already described, 
considerable difficulty and delay are often encountered in finding 
the canal back of the obstruction, owing to the thickening and 
oedema of the perineal tissues. 

In the other, the knife is at once directed upon the urethra poste- 
rior to the stricture, without any previous attempt at division of the 
latter, which may afterwards be accomplished or not at the surgeon's 
option. This method was favorably mentioned by Mr. Liston, 1 and 
highly recommended by the late Mr. Guthrie. 2 The same prepara- 
tion of the patient is to be made as for rectal puncture. The left 
forefinger is then introduced into the rectum, and a narrow, sharp- 
pointed bistoury, held in the opposite hand, with its back towards 
the bowel, made to penetrate the superficial tissues of the perineum 
to the depth of about an inch a little above the verge of the anus, 
and, cutting upwards in the median line, to form an incision an inch 
and a half to two inches in length. Fluctuation may often be 
detected by a finger inserted in the wound thus made, especially if 
the patient be directed to strain ; and, when present, will serve to 
guide the point of the knife, which should open the urethra back of 
the obstruction, in the membranous portion, or possibly as far back 
as the apex of the prostate. Before withdrawing the blade, a director 

1 Practical Surgery, 4th ed., p. 484. a Lettsomian Lecture, 1851. 



PUNCTURE THROUGH THE SYMPHYSIS. 331 

should be passed into the bladder to facilitate the subsequent intro- 
duction of a female catheter, which, in case the operation is to 
rest here, must be fastened in place by a bandage ; or a probe may 
be insinuated through the stricture from behind forwards, to meet 
a catheter introduced from the meatus, and the obstruction divided 
upon it ; when the subsequent steps will be the same as after peri- 
neal section. 

Puncture above the Pubes. — This operation, which was a 
favorite with Abernethy, and according to Dr. Wilmot, 1 is practised 
by Dublin surgeons in preference to recto-vesical puncture, has not 
been so generally adopted in this country as the preceding methods. 
It is entirely inadmissible when the bladder is contracted, and diffi- 
cult of performance when the patient is corpulent ; though in spare 
subjects, with the bladder much distended, its execution is very easy. 
The chief danger attending it is from infiltration of urine, which 
should be guarded against by making a free external incision, and 
by leaving the canula in place for twenty-four or thirty-six hours, 
and until lymph has been effused around it, before substituting a 
gum-elastic instrument. Fatal results have sometimes ensued from 
sloughing of the edges of the wound, and also from perforation of 
the peritoneum. 

In performing this operation, the patient should be placed in a 
semi-recumbent posture, with the hair shaved from the pubes ; an 
incision is to be made above the symphysis involving the integu- 
ment and cellular tissue to the extent of about two inches in a 
vertical direction; the pyramidal muscles may now be separated 
with the handle of the scalpel, and the bladder felt for by a finger 
introduced into the wound ; the trocar, either straight or slightly 
curved, with its concavity downwards, should be inclined towards 
the lower portion of the sacrum, and a gum-elastic catheter substi- 
tuted for the canula at the end of one or two days. 

Puncture through the Symphysis. — This operation has been 
too infrequently practised to admit of an expression of opinion 
regarding it. It was first proposed by Dr. Brander, 2 in 1825, and 
since performed by him ; by Dr. Leasure, 3 of New Castle, Pa., and a 
few others. Its execution is very simple, consisting merely in intro- 
ducing a trocar, by a rotatory motion, either with or without a 

i Stricture of the Urethra, 1858. 

2 Seances de l'Athenee de Me"d., Paris, 1825; referred to by Thompson. 

s Am. Journ. of the Med. Sci., April, 1854, p. 403. 



332 STRICTURE OF THE URETHRA. 

previous incision through the integument, between the pubic bones, 
in the direction of the promontory of the sacrum, and afterwards 
inserting a piece of flexible catheter through the canula. Should its 
safety be proved by farther experience, it will possess the advan- 
tage, as suggested by Dr. Leasure, of enabling the surgeon, in the 
absence of other instruments, to relieve retention by means of a 
sinrple hydrocele trocar. 

TREATMENT OF EXTRAVASATION. 

The general principles upon which the treatment of extravasation 
of urine is to be conducted are : To give free exit by incisions to the 
escaped fluid and disorganized tissues ; to support the vital powers 
by nourishment and stimulants; to remove and render inert the 
noxious products of decomposition by cleanliness and antiseptics. 
At the earliest moment that any external symptoms of extravasa- 
tion can be detected — nay, before this, if constitutional shock and 
deep-seated pain lead to the suspicion of the escape of urine, although 
its presence behind the deep perineal fascia be indicated by no sign 
appreciable upon the surface — a free incision should be made in the 
median line of the perineum, where there is but little danger of 
wounding important vessels. When the extravasation has attained 
more superficial parts, numerous incisions are required in the scro- 
tum, and wherever else there is distention and a tendency to slough- 
ing or gangrene. 

We are generally called upon to sustain the sinking powers of 
life by the free exhibition of nourishment and stimulants ; as beef 
tea, brandy, milk punch, carbonate of ammonia, quinine, etc. Opium 
is of value when there is much pain or nervous irritability. Nothing 
can be done for the relief of the stricture during the continuance 
of the shock consequent upon rupture, but usually, as this passes 
off, catheterism may be successfully performed. In case this cannot 
be accomplished, and if the bladder be found on percussion to be 
still distended, owing to the small size of the rupture, it is desirable 
to resort to puncture at once, or to extend the incision in the peri- 
neum to the urethra behind the obstruction. The discharge is fetid 
and ammoniacal from the first, and especially so as the disorganized 
tissues are cast off by suppuration ; hence frequent ablutions, poul- 
tices with the addition of Labarraque's solution, or bags of powdered 
charcoal, and antiseptic lotions are required. 

TREATMENT OF URINARY ABSCESS AND FISTULA. 

Urinary abscess, as already observed in the present chapter, may 
arise from ulceration of the urethra and consequent escape of urine, 



TREATMENT OF URINARY ABSCESS AND FISTULA. 333 

often in minute- quantity, into the cellular tissue, in which case it 
communicates with the canal from the outset ; or it may be produced 
by simple irritation of the neighboring parts, and, although isolated 
at first, eventually open into the urethra. In both cases the sooner 
the abscess is evacuated by external incision, the better ; in the for- 
mer, in order to quiet the constitutional disturbance which ordinarily 
ensues, and prevent the extension and burrowing of matter ; in the 
latter, to effect the same purpose, and also to avoid, if possible, any 
lesion to the urethral walls and the formation of urinary fistula ; for 
when once the urine has found an abnormal outlet, it acts as a con- 
stant irritant, and renders difficult the closure of the passage either 
by nature or by art. When matter is pent up behind the triangular 
ligament, it is often exceedingly difficult to detect its presence by 
external examination; there is usually, however, even in obscure 
cases, some degree of hardness and tenderness on pressure, and if its 
existence is rendered probable by the general symptoms, as a chill, 
nausea, rapid pulse, etc., an incision should at once be made in the 
median line of the perineum in front of the anus ; even if pus be 
not at first found, a passage will be formed for its subsequent exit, 
and the tension of the parts will be relieved. In some exceptional 
cases, urinary abscess assumes a chronic character, and is attended 
by little febrile excitement or inconvenience ; thus, a small tumor, 
formed by an abscess communicating with the urethra, 'sometimes 
exists for months before being discovered by the patient or surgeon, 
unless a careful examination of the perineum be made. 

Urinary fistulse, in most cases, contract and close spontaneously 
when the stricture has been thoroughly dilated, especially if the 
general condition of the patient be maintained at a proper standard 
of health. Assistance may be derived from stimulating applications 
to the sinus ; as of nitrate of silver, nitric acid, tincture of cantha- 
rides or iodine, etc. The end of a probe may be coated with nitrate 
of silver and passed along the fistulous track ; one of the tinctures 
just mentioned, either pure or diluted with water, may be injected ; 
and plugs of compressed sponge may occasionally be inserted to 
advantage. Fistulas in front of the scrotum frequently require plas- 
tic operations, a description of which may be found in works on 
general surgery. 



PART II. 
THE CHANCROID AND ITS COMPLICATIONS. 



CHAPTER I. 

THE CHANCROID. 

I adopt the name of "chancroid" to designate the "contagious 
and local ulcer of the genitals," the history of which has been given 
in the introduction of the present work. 

This ulcer arises only in consequence of contagion from its like, 
and secretes a fluid capable of reproducing itself when implanted 
beneath the epidermis or epithelium of any portion of the skin or 
mucous membranes. Its secretion may be taken up by the lym- 
phatics and conveyed to the nearest ganglion, there to set up inflam- 
mation and the formation of matter possessing the same power of 
reproduction as the secretion of the sore itself; but its farther pro- 
gress is arrested within the ganglion ; it never gains access to, or 
contaminates the general circulation ; and, since its influence is thus 
confined to the neighborhood of the point of implantation of the 
virus, the ulcer is said to be local. 

This sore is the " simple," " soft," " non-infecting," or " non-indu- 
rated chancre " of various authors ; the " chancrelle " of Diday ; and 
the " chancre " of Hebra, Zeissl, Eeder, and others of the modern 
German school. 1 

Frequency. — Chancroids constitute by far the larger proportion 
of venereal ulcers resulting directly from contagion. Of 341 such 
sores observed at the H6pital du Midi in the course of three months, 
215 were chancroids. M. Puche has prepared a table of all venereal 
ulcers under treatment at the same hospital during ten years (1840- 
1850), forming a total of 10,000, of which 8045 were chancroids and 

1 See Introduction, p. 52. 

(335) 



336 CHANCROID. 

1955 were chancres ; * in other words, the ratio of the former to the 
latter was nearly as 4 to 1. The statistics of other observers vary 
somewhat from the above, but they all concur in showing the much 
greater frequency of the chancroid. Ricord explains this difference 
on two grounds : first, that the chancroid furnishes a more copious 
secretion, and generally for a longer period, than the chancre ; and, 
secondly, that an attack of the former, unlike one of syphilis, affords 
no protection against subsequent contagion. 

Seat. — The chancroid is most frequently seated in the neighbor- 
hood of the genital organs, simply because these parts are most 
exposed to contagion and not in consequence of any peculiar apti- 
tude which they possess. If the chancroidal virus be inserted 
beneath the epidermis of any other part of the body a chancroid is 
equally the result. Nor is this the limit to its seat : it is also found 
within various mucous canals — as the urethra, vagina, and rectum 
— opening upon the surface, at as great a depth as these passages 
can be explored by the senses during life ; and post-mortem exami- 
nations have proved the possibility of its presence in the bladder, 
though such instances are extremely rare. The whole external in- 
tegument, and whatever portions of the mucous membranes are 
accessible to the implantation of the virus, are therefore exposed to 
become its seat. The frequency with which it is met elsewhere than 
upon the genitals, depends in -a great measure upon the habits and 
cleanliness of persons exposed to contagion. 

The following table exhibits the seat of 343 chancroids, comprising 
all that were observed at the Hopital du Midi, in the year 1856. 2 

On the glans and prepuce 296 

On the skin of the penis 15 

On various parts of the penis 17 

Involving the meatus .....*.... 9 

Within the urethra (not visible on forced separation of the lips of the 
meatus, but recognized by inoculation, palpation, inflammation of 

the lymphatics, etc.) ......... 3 

On the anus ........*.. 2 

On the fingers ........... 1 

A singular exception to the rule that all portions of the body are 
equally prone to contract a chancroid has been noticed, viz., that 
this ulcer is rarely, if ever, met with in practice upon the head or 
face, where, on the contrary, the initial lesion of syphilis is not 

1 Foi'RNiER, Lecons sur le Chancre, p. 15. 

2 Fouenikr, Lecons sur le Chancre, p. 252. 



SEAT OF THE CHANCROID. 337 

uncommon. At one time this fact excited no little discussion, since 
it was supposed to conflict with the distinct nature of the chancroid 
and syphilis, and to favor the idea that the seat of the contagion 
exerted an influence either for or against contamination of the 
general system, and hence that the chancroidal and syphilitic poisons 
were one. 

The important bearing of this question led to an extensive 
investigation for the purpose of ascertaining if the alleged exemp- 
tion was founded on fact. Fournier l took a prominent part in this 
labor, and, from a diligent search through medical works and inquiry 
of those who made a special study of venereal, was able to collect 
150 cases of venereal ulcers upon the head and face, all of which, 
however, with the exception of 5, were chancres. These five 
exceptional cases, in which the ulcer was supposed to be a chan- 
croid, had been observed by MM. Eicord, Venot, Devergie, Basse- 
reau, and Diday ; but Eicord confessed that his case, an ulceration 
at the base of one of the superior incisor teeth (figured in his Icono- 
graphie, pi. 21), was unreliable, and the other four were all imper- 
fectly reported ; and thus there could remain no doubt of the rarity, 
if not of the entire absence, of the chancroid upon the region in 
question. 

Among the various theories offered in explanation, the one 
advanced by MM. Diday and Fournier was perhaps the most pro- 
bable, viz., that the absence of the chancroid upon the head and 
face is due to local idiosyncrasy, similar to that which leads many 
other diseases to select certain regions, and avoid others of the same 
anatomical structure. Thus, gonorrhoea, croup, and rheumatism, 
attack respectively the eye, larynx, and pericardium, and spare the 
nose, oesophagus, and peritoneum ; and scabies is never met with 
upon the face. Fournier was also able in several instances to trace 
oat the origin of chancres upon the head and face, and found that 
there was never an interchange of the two species, but that they 
invariably arose from syphilitic contagion; hence, admitting the 
absence of the chancroid upon this region in clinical experience, it 
constitutes no argument against a double virus. 

It has been since ascertained that the chancroid can be developed 
upon the head and face by artificial inoculation. Puche 2 and Eollet 3 
have inoculated its virus with success upon different parts of the 

1 Etude sur ie Chancre CSphalique, Union Medicale, Feb. and March, 1858. 

2 Nadau des Islets, De 1' Inoculation du Chancre mou a la F»6gion C6phalique, 
These de Paris, 1858. 

s Gaz. M6d de Lyon, Dec, 1857. 

22 



338 CHANCROID. 

head in 20 instances ; Bassereau 1 and Prof. Huebbenet, 2 of Kieff, 
upon the lips and cheeks in five; Eobert 3 upon the temple, nose, and 
lips in three, and in all the sore so produced was entirely from indu- 
ration, and was not followed by secondary symptoms — a fact which 
utterly demolishes the argument of the "unicists." 4 At the same 
time it must be admitted that the extreme rarity of the chancroid 
upon the head and face is not as yet fully explained. The ease with 
which the above-mentioned inoculations took effect does not favor 
the idea of local inaptitude, as supposed by MM. Fournier and 
Diday. The preponderance of primary syphilis over the chancroid 
may readily be accounted for, as suggested by Eollet, on the ground 
that syphilis is often transmitted by secondary lesions which are 
very common in the buccal cavity, and that contact is no less fre- 
quent and intimate between mouth and mouth than between the 
genital organs of the two sexes ; but we are still at a loss to explain 
the almost entire absence of the chancroid in clinical experience 
upon the region referred to. 

I shall content myself with this brief sketch of the discussion 
relative to the "cephalic chancre," which for a time attracted no 
little attention, but which assumes less importance now that it is 
known not to conflict with a duality of poisons. Its only practical 
bearing is this: that the rarity, if not the entire absence of the 
chancroid upon the head and face, furnishes strong ground of belief 
that any venereal ulcer met with upon this region is syphilitic. 

Contagion. — The vehicle of the chancroidal virus is the secre- 
tion of the ulcer, and, more definitely, the contained pus-globules ; 
for, according to Rollet's experiments, if the chancroidal secretion 
be freed from pus-globules by filtration, the remaining fluid is 
innocuous. 

When kept from contact with the air at a moderate temperature, 
the chancroidal virus preserves its power of contagion for a consid- 
erable length of time. Ricord states that he has inoculated it with 
success after preserving it in glass tubes hermetically sealed for 

1 Buzenet, Du Chancre de la Bouche, These de Paris, 1858, p. 41. 

2 L' Union Mgdicale, May 20, 1858. 

3 Nouveau Traite" des Mai. V6n6riennes, Paris, 1861, p. 380. 

* Robert's reply to this, that a chancroid may be forced upon the tissues of the 
head and face by artificial inoculation, but that the same tissues will develope a 
syphilitic ulcer even from the chancroidal virus, when contaminated in coitu, appears 
to me weak and puerile. What possible difference upon the development of the sore 
can it make, whether the virus is deposited by the surgeon's lancet or by the penis 
in connection ab ore? 



CONTAGION. 339 

seventeen days. Sperino relates a remarkable instance of its pre- 
servation. A lancet which had been employed in artificial inocula- 
tion had been laid aside for seven months, when it was observed 
that a small quantity of dried pus had been left upon its point. The 
instrument was moistened,' and three punctures made with it gave 
rise to as many chancroids. If exposed to a high degree of tem- 
perature, or if mixed with alcohol, an acid, or alkali, the chancroidal 
virus becomes innocuous. If frozen and then thawed, it may still be 
inoculated. Dilution with from six to ten times its quantity of 
water does not destroy its potency ; but it is said that if two inocu- 
lations be made, one with diluted and the other with pure matter, 
the ulcer produced by the former will be smaller, although just as 
persistent as the one from the latter. 1 Mixture with vaccine, gonor- 
rhoea!, or syphilitic matter does not impair its power ; it may thus 
be transmitted in the procees of vaccination, and its communication 
in common with the syphilitic vir"us gives rise to the so-called 
" mixed chancre." 

Simple contact of the chancroidal virus with a raw surface is suf- 
ficient to give rise to a chancroid. The most favorable condition for 
contagion to take place is the presence of abrasions or other solu- 
tions of continuity, such as are frequently occasioned by violence 
during coitus, and through which the poison may penetrate beneath 
the epidermis or epithelium. The application of virulent matter to 
the sound external integument hardened by exposure and friction, 
is as innocuous as the deposit of vaccine virus upon the skin with- 
out previous puncture. The surgeon frequently soils his fingers 
with the secretion of chancroids, and this with impunity so long as 
their surface is intact, but the slightest abrasion is liable to be 
inoculated. 

Cullerier's experiments relative to mediate contagion establish the 
fact that virulent pus may be retained for some time in contact with 
even a delicate mucous membrane, as the walls of the vagina, with- 
out effect. As a general rule, however, mucous surfaces offer a much 
less effectual barrier to contagion than the external integument, and 
are, therefore, most frequently the seat of chancroids. Even when 
no solution of continuity has prepared the way, the virus deposited 
upon the surface, in some fold of the membrane or in an open folli- 
cle, may act as an irritant, produce a superficial erosion, and thus 
gain entrance beneath the surface. The greater or less time occu- 
pied by this process will account in a measure for the variable period 
after exposure at which the chancroid appears. 

1 Reder, Pathologie und Therapie der Venerischen Krankheiten, Wien, 1863, p. 142 



340 CHANCROID. 

The so-called practice of syphilization affords ground of belief 
that the susceptibility of the skin to the development of chancroids 
generally diminishes under repeated inoculations, until finally tem- 
porary immunity is obtained. This is not always the case, however, 
for Lindmann, a German medical studerit at Paris, succeeded in in- 
oculating himself 2500 times with the chancroidal virus. When 
repeated inoculation with the same virus at last fails, virus from a 
fresh source will often succeed. 

The transfer of matter necessary to contagion most frequently 
takes place in a direct manner during coitus. Since the chancroid 
rarely, if ever, occurs upon the mouth or face, instances of "mediate 
contagion" through the intervention of some article in common use, 
as a towel, drinking vessel, pipe, etc., are much rarer than with the 
syphilitic virus. There is reason to believe, however, that in rare 
instances virulent pus may be transported from one person to an- 
other by the genital organs of a third, which merely serve as a 
vehicle,' and are not themselves inoculated. For instance, a man 
may be the medium of contagion between a woman of the town and 
his own wife, while he himself escapes ; or, with greater probability, 
a woman may be the bearer of contagion between two men. To 
test the possibility of such an occurrence, M. Cullerier instituted the 
following experiment : — 

Louise Yaudet entered the Lourcine Hospital Oct. 10, 1848, to be 
treated for an ulcer of a grayish aspect and with sharply cut edges 
in each groin, which had already persisted without treatment for a 
month. There was considerable surrounding inflammation, which 
was subdued by rest and poultices, when the genital organs and anus 
were carefully examined and found to be free from ulceration. The 
vagina was reddened and smeared with an abundant muco-purulent 
secretion, but its mucous surface was intact and the os uteri healthy. 
The inguinal ulcers were dressed with charpie moistened in aromatic 
wine, and vaginal injections of a solution of alum ordered; under 
which treatment the sores and vaginitis rapidly improved. 

Nov. 25, after finding on a second examination that the mucous 
membrane of the vulva and vagina was, as before, intact, and after 
inoculating without success the vaginal secretion, M. Cullerier col- 
lected upon a spatula a considerable quantity of pus from the ulcers 
in the groins and deposited it in the vagina. The patient was then 
directed to walk about under surveillance lest she should touch the 
parts, and at the end of thirty-five minutes was again placed upon 
the bed, and some of the fluid found in the vagina was inoculated 
upon her thigh. The vagina and vulva were then freely washed with 
water, dried, and washed a second time with a solution of alum. Two 



INOCULATION. 341 

days after, the inoculation had produced the characteristic pustule 
of a chancroid, which was left another twenty-four hours to confirm 
the diagnosis and then destroyed with Vienna paste. Repeated sub- 
sequent examination showed that no ulceration had been caused in 
the vagina, which was not even more inflamed than before. In two 
months the patient left the hospital cured of both her vaginitis and 
inguinal ulcers. 

In a second case in which this experiment was performed, the pus 
was allowed to remain in the vagina for nearly an hour and did not 
take effect. 1 

Inoculation. — Since artificial inoculation is the best, and indeed 
the only sure test of the presence of the chancroidal virus, the steps 
of the process and the ensuing phenomena require special description. 

In performing artificial inoculation, some convenient part' of the 
integument of the person bearing the ulcer, as the arm, thigh, or 
abdomen, is selected, and a superficial puncture made beneath the 
epidermis, as in inoculating the vaccine virus. The lancet employed 
should be new, or freshly ground, and little, if any, blood should be 
drawn, lest it wash away the virus, and invalidate the experiment ; 
if more appear than is barely sufficient to redden the part, a fresh 
puncture should be made. Some of the secretion which it is desired 
to test should now be inserted in the wound, and the inoculated point 
covered with a watch-glass to protect it from abrasion. The glass 
is retained in place by strips of adhesive plaster arranged around its 
margin, and leaving the centre free through which the effect may be 
observed. If the inoculation be successful, the point of puncture 
becomes red in the course of a few hours ; by the second or third 
day, it has swollen, and forms a small papule, surrounded by a red- 
dish areola ; on the third or fourth day, the epidermis is raised by 
an effusion of serum which soon becomes turbid from an admixture 
of pus ; by the fifth day the fluid is decidedly purulent, and forms a 
pustule, the summit of which is often umbilicated like the pustule 
of variola ; meanwhile, the surrounding areola has been increasing 
in width and depth of color, and has now attained its height. The 
pustule thus formed is often termed the " characteristic pustule" of 
a successful inoculation, and is identical in appearance with the pus- 
tule of ecthyma ; if any doubt remain as to its nature, its secretion 
may be tested by a second inoculation. If the pustule be left un- 
broken, the contained matter concretes, and forms a scab of conical 

1 Quelques Points de la Contagion mediate. Memoires de la Soc. de Chir., quoted 
in Legons sur le Chancre, p. 255. 



342 CHANCROID. 

form, which increases by additions to its circumference. If this scab 
be removed, an ulcer is found beneath it, which may be regarded as 
the type of a chancroid. Its peculiarities are, that it penetrates the 
whole thickness of the skin or mucous membrane, so that its floor 
is formed by the subjacent cellular tissues ; its edges are abrupt, 
jagged, and often slightly undermined ; its outline is circular; its 
surface is of a grayish color and uneven, presenting slight eleva- 
tions and depressions which are best seen through a magnifying 
glass. The tendency of this ulcer is to extend, or, at least, not to 
diminish, for weeks ; and in this it again differs from the pustule 
and more superficial ulceration, which may be induced by the inocu- 
lation of simple but irritant matter. 

Such is the evolution of a chancroid after artificial inoculation, as 
observed by Ricord and others, in many thousand instances. 

At the time Ricord performed his experiments the distinct nature 
of the chancroid and syphilis was unknown, and supposing he was 
inoculating the syphilitic virus, he was led to infer, that successful 
auto-inoculation was a test of the initial lesion of syphilis ; that a 
3hancre was destitute of a period of incubation, and that it fre- 
quently commenced as a pustule — conclusions which are now known 
:o be applicable only to the chancroid. 

It would be improper to leave this subject without uttering a few 
words of caution to those who would practise artificial inoculation 
as a means of diagnosis. If the inoculation prove successful the 
resulting pustule should be laid open at the earliest moment after 
its character has been determined, its cavity be carefully cleansed, 
and the ulcer thoroughly destroyed by the application of nitrate of 
silver, Vienna paste, or nitric acid. If destructive cauterization be 
delayed for even twenty-four hours, the neighboring tissues may 
become so infiltrated with the virus that the most thorough applica- 
tion will fail to include them all, and a most troublesome and per- 
sistent ulcer be the result. I have myself seen two such cases ; one in 
the New York Hospital, in which artificial inoculation, performed 
before the patient's entrance, had given rise to an extensive ulcer 
upon the thigh of several years' duration ; and another in the Penn- 
sylvania Hospital, Philadelphia. Other cases are reported in works 
on venereal. With due caution, however, this accident may be 
avoided, and artificial inoculation be employed with safety for the 
purposes to which it is applicable. 

Symptoms. — The phenomena following artificial inoculation as 
above described, exhibit the mode of evolution of the chancroid, and 



SYMPTOMS. 348 

the various forms it may assume. It is not preceded by a period of 
incubation. The ulcerative process commences immediately upon 
implantation of the virus, and is sufficiently advanced to attract the 
notice of the patient in from one to eight days after contagion. The 
late period at which it is observed in a few instances is to be ascribed 
to the contagious matter having remained for some time upon the 
surface before penetrating beneath the epidermis or epithelium, or 
else to the sore having been overlooked. 

When the part inoculated is the internal surface of a follicle or 
fissure, the mouth or edges of which close over the imprisoned virus, 
the resulting chancroid first appears as a pustule or small abscess, 
which remains intact for a longer or shorter period, according as it 
is protected, or not, from abrasion. The pustular form is, however, 
not common, except as the result of artificial inoculation — or, 
rather, the pustule is usually ruptured before the patient comes 
under observation, and only the ulcer beneath it remains. When 
contagious matter has inoculated a previous solution of continuity, 
the chancroid is from the outset an open sore, at first correspond- 
ing in shape and size to the fissure, rent, or abrasion, in which it is 
developed, and gradually assuming the more marked characters of 
a specific ulcer. 

The chancroid, when fully formed, presents the following symp- 
toms : its outline is circular, unless modified by the shape of the 
solution of continuity in which it is implanted ; by a difference in 
the density of the tissues beneath it, as when seated upon the margin 
of the glans penis and prepuce, when it extends most rapidly in 
whatever direction the tissues are most lax ; or, by the union of 
several adjacent chancroids, when the resultant ulcer may be very 
irregular. Chancroids upon the free margin of the prepuce appear 
like slits or fissures while the glans is covered, but when the latter 
is exposed, are found to be nearly circular. 

The rapid perforation of the skin or mucous surface by the chan- 
croid, appearing as if a portion of the membrane had been punched 
out, is highly characteristic of this species. The edges are jagged, 
abrupt, and sharply cut, and do not adhere closely to the subjacent 
tissues. The floor of the ulcer is uneven, studded with minute 
elevations, "worm-eaten," and covered with a pseudo-membranous 
secretion of a grayish-yellow color, which cannot be removed with- 
out violence. The fluid secretion is copious and purulent ; under 
the microscope it is found to consist of pus-globules mixed with 
organic detritus. 

The chancroid is surrounded by an areola which varies in width 



344 CHANCKOID. 

and depth of color with the degree of attendant inflammation. The 
condition of the tissues around and beneath it is one of the most 
important elements of diagnosis between this and a true chancre. 
In the form we are now considering, the parts always preserve their 
normal softness and suppleness, unless subjected to some irritant, or 
attacked by simple inflammation. Inflammatory engorgement, how- 
ever, is not well defined like the specific induration of the initial 
lesion of syphilis, but gradually subsides into the normal suppleness 
of the neighboring tissues, to which it is adherent ; it is also less 
firm, and of a more doughy feel, and disappears shortly after the 
cessation of the inflammation which occasioned it. The application 
of any astringent lotion, or caustic, as nitrate of silver, potassa fusa, 
nitric acid, etc., may cause hardness which so closely resembles 
specific induration, that it cannot be distinguished from it, except 
by its shorter duration ; and, for the time being, the diagnosis must 
be founded upon other symptoms. Still another source of error is 
the possibility of a chancroid being situated upon the persistent 
induration of a previous chancre. 

Chancroids are more frequently multiple than single. Of 254 
patients in the Hopital du Midi, 48 bore one, and 206 several ; and 
of the latter, 116 had from three to six ; 41 from six to ten ; 8 from 
ten to fifteen ; 4 from fifteen to twenty ; and 5 over twenty. 1 Of 
118 patients in the Antiquaille Hospital at Lyons, affected with 
, chancroids, 50 presented one, and 68 several. 2 When but one chan- 
croid appears at the outset as the immediate result of contagion, 
others are apt to spring up around it from successive inoculation, 
since the original ulcer pours out an abundant secretion, and its 
presence confers no immunity against others. 

The chancroid is very persistent. Unless it can be destroyed by a 
strong caustic or otherwise, it will generally last for weeks and may 
last for months, however skilfully treated either by local or constitu- 
tional remedies. Fournier has shown that it may be inoculated up-on 
the person bearing it up- to the time when cicatrization is nearly com- 
plete: as Eicord expresses it, the specific period of the chancroid 
absorbs nearly the whole of its existence. Unless complicated with 
phagedena, however, this ulcer is self-limited, and will in time heal 
spontaneously, without other treatment than attention to cleanliness. 
The average duration of the destructive period may be estimated 
at about four weeks, during which a portion of the neighboring 
tissues are destroyed and the edges of the sore are undermined. 

1 Fournier, op. cit., p. 41. 

2 Dfbauge, Traitement des Chancres Simples, etc., These de Paris, 1858, p. 6. 



DIAGNOSIS. 345 

During the fifth week the progression of the ulcer ceases; the sur- 
rounding hypersemia, oedema, and redness disappear; granulations 
spring up, commencing at the periphery; and cicatrization goes on 
towards the centre. During either the progressive or reparative 
stage, the application of fresh water will produce a new contagion 
which will run the same course as the original ulcer. 

In the majority of cases of the chancroid, the neighboring lym- 
phatic ganglia remain intact throughout the whole course of the 
disease. In the remaining minority, these bodies take on inflamma- 
tory action, either firstly — as the result of sympathy with, or the 
extension of simple inflammation from, the local ulcer, or secondly — ■ 
in consequence of the absorption and conveyance to the ganglion of 
the chancroidal virus. In the former case (inflammatory or sympa- 
thetic bubo), resolution is possible without suppuration ; in the latter 
(virulent bubo), suppuration is inevitable. Of 267 cases of chan- 
croid observed at the H6pital du Midi in one year, 65 were attended 
with bubo, and 142 were not. 1 Of 140 patients in the service of M. 
Eollet, at Lyons, 52 were free from inguinal reaction, while 83 had 
buboes of which 60 were virulent. 2 "We shall see hereafter that the 
initial lesion of syphilis is always attended with induration of the 
nearest lymphatic ganglia, which rarely become inflamed and sup- 
purate. Hence an examination of the condition of the ganglia in 
the neighborhood of a venereal ulcer affords assistance of the highest 
value in distinguishing a chancroid from primary syphilis. 

Diagnosis. — The chancroid is apt to be confounded with a simple 
abrasion, with herpes, and with the initial lesion of syphilis. 

An abrasion due to violence during coitus will be recognized by 
tne patient himself — unless intoxicated — either at the time of its 
occurrence, or during those reflective moments which follow the 
exposure, when, as Aristotle sententiously remarks : " omne animal 
post coitum triste." Independently of its history, an abrasion may 
often be recognized by the jagged outline of its edges and by the 
appearance of its surface "and its secretion, differing, as they do, from 
those of a chancroid already described. Subsequent neglect, a low 
condition of the general system, the accumulation of filth or even 
of the natural secretion of the part, may perpetuate the solution of 
continuity thus made, and transform it into an ulcer which can with 
difficulty be distinguished from a chancroid ; and the diagnosis can 
only be made either by artificial inoculation or by waiting for farther 

i Fournier, op. cit., p. 34. 2 Dkbauge, op s cit., p. 72. 



346 CHANCROID. 

developments, at the same time paying attention to cleanliness and 
to general hygiene. "But," it may be said, "an abrasion occurring 
at the time of coitus may have served as the door of entrance either 
to the chancroidal or syphilitic poisons." Very true; and conse- 
quently when a patient seeks advice, a day or two after coitus, with 
a solution of continuity evidently due to violence, the surgeon can 
only estimate its present but not its future character. Under such 
circumstances, a guarded opinion only should be given, as, for 
instance, " You have torn yourself in the sexual act ; but whether 
you have been inoculated or not through the rent, I cannot say j 
time will determine." A mere abrasion or tear, in a healthy consti- 
tution and under conditions of cleanliness, will heal in the course 
of a few days ; while an abrasion inoculated with the chancroidal 
virus will extend and assume the character of a chancroid. 

An eruption of herpes usually appears on the first or second day 
after exposure, and consists of a number of small vesicles which are 
arranged in one or more groups affecting the form of a circle. The 
contained fluid soon becomes turbid, and if the epidermis be rup- 
tured or removed, a superficial ulceration is found beneath. With 
attention to cleanliness and the interposition of a piece of dry lint 
between the glans and prepuce, the vesicles or erosions will usually 
heal in the course of a few days. Their circular arrangement, 
small size, watery fluid, superficial character, and speedy cicatriza- 
tion, present a marked contrast to the symptoms of the chancroid ; 
and artificial inoculation may be resorted to in the few cases in 
which a doubt is possible. Many men, especially those with a long 
prepuce, are subject to attacks of herpes after intercourse with any 
woman however pure, and the patient's previous history in this 
respect should therefore be inquired into. 

A recital of the diagnostic symptoms between the chancroid and 
the initial lesion of syphilis would be but to rehearse the symptoms 
of these two lesions given at length in this and a subsequent chap- 
ter. They can best be contrasted in the synoptic table at the close 
of the present section. 

In determining the nature of a suspected sore, no opportunity 
should be neglected of examining the person from whom the disease 
was derived. Since there is never an interchange between the 
chancroid and syphilis, the symptoms presented by the giver of 
the ulcer will throw light upon the nature of the disease in the 
recipient. The absence of induration, the presence of a suppurating 
bubo, or, provided no general treatment has been administered, the 
non-appearance of general symptoms within three months after con- 



TREATMENT. 



347 



tagion in the former, will indicate that the latter has a chancroid. 
On the contrary, if a person with an indurated nicer or with general 
syphilis, communicate a sore to another, the latter, without doubt, 
has a chancre. This method of arriving at a diagnosis is of special 
value in married life. In several instances, when informed by hus- 
bands affected with syphilis that they had communicated their dis- 
ease to their wives, I have been able to treat the latter by means of 
specific remedies without making an examination, and have thus 
avoided a disclosure which could accomplish no possible good, and 
would surely have been productive of much misery. 

DIAGNOSTIC CHARACTERS OF THE CHANCROID AND CHANCRE. 



THE CHANCROID. 

Origin. 
Always derived from a chancroid, or virulent 

bubo. 
Has no period of incubation. 
Anatomical characters. 
Generally multiple, either from the first or by 

successive inoculation. 

An excavated ulcer, perforating the whole 
thickness of the skin or mucous membrane. 



Edges abrupt and well-defined, as if cut with 
a punch, not adhering closely to subjacent 
tissues. 

Surface flat but uneven, " worm eaten," 
wholly covered with grayish secretion. 

No induration of base unless caused by 
caustic or other irritant, or by simple in- 
flammation ; in which case the engorge- 
ment is not circumscribed, shades off into 
surrounding tissues, and is of temporary 
duration. 
Pathological tendencies. 

Secretion copious and purulent, auto-inocu- 
lable. 



Slow in healing. Often spreads and takes on 
phagedenic action. 

May affect the same person an indefinite 
number of times. 
Characteristic gland affection. 

Ganglionic reaction absent in the majority 
of cases. When present, one gland acutely 
inflamed and generally suppurates. Pus 
often inoculable, producing a chancroid. 

Prognosis. 
Always a local affection, and cannot infect 
the system. " Specific" treatment by mer- 
cury and iodine always useless, and, in 
most cases, injurious. 



THE CHANCRE. 
Origin. 

Always derived from a chancre or syphilitic 
lesion. 

Has a period of incubation. 
Anatomical characters. 

Generally single ; multiple, if at all, from the 
first ; rarely, if ever, by successive inocula- 
tion. 

Frequently a superficial erosion ; not involv- 
ing the whole thickness of the skin or 
mucous membrane, of a red color and 
nearly on a level with the surrounding 
surface. Sometimes an ulcer, when its 

Edges are sloping, hard, often elevated, and 
adhere closely to subjacent tissues. 

Surface hollowed or scooped out, smooth, 
sometimes grayish at centre. 

Induration firm, cartilaginous, circumscribed, 
movable upon tissues beneath. Sometimes 
resembles a layer of parchment lining the 
sore. Generally persistent for a long pe- 
riod. 

Pathological tendencies. . 

Secretion scanty, chiefly serous; inoculable 
with great difficulty, if at all, upon the pa- 
tient or upon any person under the syphi- 
litic diathesis. 

Less indolent than the chancroid. Pha- 
gedena rarely supervenes and is generally 
limited. 

One attack affords complete or partial pro- 
tection against a second. 
Characteristic gland affection. 

All the superficial inguinal ganglia, on one 
or both sides, enlarged and indurated; 
distinct from each other, freely movable; 
painless, and rarely suppurate. Pus never 
inoculable. 
Prognosis. 

A constitutional affection. Secondary symp- 
toms, unless prevented or retarded by treat- 
ment, declare themselves in about six 
weeks from the appearance of the sore, 
and very rarely delay longer than three 
months. 



Treatment. — The chancroid, unless complicated with phagedena, 
is in most cases self limited, and, in the absence of all treatment 



348 CHANCKOID. 

other than cleanliness, will heal spontaneously in the course of from 
six to eight weeks. Its duration, however, can be shortened by art, 
and the danger of the formation of a bubo diminished. 

The internal use of mercury has no beneficial influence whatever 
upon the chancroid, which continues in a state of stubborn persist- 
ency, or even progresses, after the system is fully under the influence 
of this mineral. This statement is not a mere inference from the 
distinct nature of the chancroid and syphilis, but is founded upon 
experience. I was fully convinced of the fact by personal observa- 
tion, and ceased to employ mercury for "soft chancres," several 
years before the distinction between the two species was recognized. 
Since abandoning it in my own practice, I have had numerous 
opportunities of observing other surgeons administer mercurials for 
the chancroid, and my former opinion has only been confirmed. A 
few years since, during three weeks' absence from the city, I com- 
mitted five patients with chancroid to the care of a medical friend, 
and, on my return, found them all salivated, and in every one the 
sore was aggravated. I could relate many similar instances, in which 
patients with simple sores have passed from other practitioners 
under my care, after going through a course of mercury without 
the slightest benefit. 

In most instances no general treatment is required except that 
which common sense would dictate, and which has for its object to 
place the patient in a healthy condition and thereby enable nature 
untrammelled to accomplish the work of cure. For this purpose, 
the secretions should be attended to ; a plain but nourishing diet 
administered ; and congestion and inflammation avoided by main- 
taining a comparative state of quietude. Nocturnal erections are 
not only painful but interfere with cicatrization, and should be con- 
trolled by the means mentioned when speaking of chordee. 

At an early period of its existence — say within from three to six 
days from its commencement — a chancroid maybe at once eradicated 
by the application of a powerful caustic, which will destroy the sur- 
rounding tissues to an extent exceeding the sphere of its specific 
influence. At a later period this object can rarely be accomplished, 
for the chancroidal virus reappears in the wound left on the fall of 
the slough ; but a repetition of the cauterization exerts a powerful 
modifying influence upon the action of the ulcer and hastens the 
reparative period. 

Destructive cauterization as a means of hastening the cicatrization 
of the chancroid, and not for the vain purpose of preventive consti- 
tutional infection, was first employed by Richond des Brus m 182(3. 



DESTRUCTIVE METHOD. 349 

This surgeon limited its use to the commencement of the sore, but 
it has since been extended by Eicord to every stage with the excep- 
tion of the reparative. 

The destructive method, if applied sufficiently early, prevents the 
occurrence of virulent buboes by removing the source from which 
the virus enters the lymphatics ; but if deferred until a bubo has 
commenced, the latter goes on to suppuration unchecked, and may 
furnish inoculable pus in the same manner as if the chancroid had 
been allowed to remain. Even the sympathetic bubo is often bene- 
fited by destruction of the ulcer and undergoes resolution. 1 

Destructive cauterization is impracticable when the chancroid 
cannot be fully exposed, as in consequence of phymosis, conceal- 
ment within the urethra, os uteri, etc. It is inadmissible in ulcers 
situated directly over the urethra either in the male or female on 
account of the danger of opening this passage ; for similar reasons, 
in chancroids of the deeper portions of the vagina, the walls of which 
are in contact with the bladder, rectum, and peritoneum ; in those 
upon the margin of the meatus, from the fear of the cicatrix occa- 
sioning stricture ; and finally in all cases in which the presence of 
other ulcers in the neighborhood, which cannot oe subjected to the 
same treatment, would expose the wound after the fall of the eschar 
to a second inoculation.' 2 

An attempt to remove the chancroid by the knife is rarely success- 
ful, since, however carefully the secretion of the sore may first be 
removed, enough usually remains to inoculate the fresh wound. For 
this reason, excision should be employed only when a cutting opera- 
tion is rendered necessary, as by the presence # of phymosis and 
threatening gangrene ; and the knife should be carried as wide as 
possible from the specific sore, and the bleeding surface be freely 
cauterized with nitrate of silver or nitric acid. On the contrary, 
the application of caustic leaves the tissues for a time protected by 
an eschar, and is, therefore, almost always to be preferred to the 
knife. 

Nitrate of silver is too feeble a caustic to be employed except at 
the commencement of a chancroid, or in wounds and abrasions im- 
mediately after a suspicious connection, before the surrounding 
tissues have become infiltrated with the virus. It is chiefly used 
for the purpose of destroying the pustule which appears on the 
second or third day after a successful inoculation. A fragment of 

• 

i Rollet, Gaz. M6d. de Lyon, March 1, 1858. 

2 De la M6thode Destructive des Chancres, par M. Dron ; Annuaire de la Syphilis 
annSe 1858, p. 202. 



350 CHANCROID. 

the solid crayon corresponding in size to the excavated ulcer which 
is exposed by the removal of the epidermis, is pressed into it and 
allowed to remain until it comes away with the small eschar which 
is formed. The simple wound which is left speedily cicatrizes. 

For the fully developed chancroid a stronger caustic is required, 
as nitric or sulphuric acid, potassa cum calce, the pernitrate of mer- 
cury, chloride of zinc, or the actual cautery. Of these, strong nitric 
acid and "Vienna paste, from the convenience of their application, 
have deservedly come into the most general use. 

Nitric acid is preferably applied by means of a glass rod with a 
rounded extremity ; a " drop bottle," with a tapering glass stopper, 
the point of which extends nearly to the bottom of the flask, is still 
more convenient ; but a simple piece of wood, as an ordinary lucifer 
match, will answer. Brushes of fine glass are objectionable, since 
the filaments are liable to break off upon the surface of the sore and 
excite irritation. The pain is for an instant very severe when the 
acid first touches the ulcer, but becomes much less acute on subse- 
quent applications, of which there should be several in order to 
render the destruction complete. I usually occupy several minutes 
in making these applications, watching the effect produced, and judg- 
ing by the changes which take place in the tissues when enough has 
been applied. Any residue should be carefully removed or neutral- 
ized by an alkali, and the neighboring surfaces be protected from 
contact by the interposition of dry lint. A water- dressing may be 
substituted as soon as suppuration takes place. 

After the fall of the eschar, the surface is still covered for a short 
time with a slimy* secretion, but this soon clears off, and any inflam- 
matory engorgement produced by the caustic subsides, leaving a 
healthy looking wound, which should be protected from the urine 
and leucorrhoeal discharges in order to insure its speedy cicatriza- 
tion. If any symptoms of a chancroid remain, the cauterization 
should be repeated. 

I am convinced that nitric acid is far superior to the nitrate of 
silver which is so commonly employed in the cauterization of the 
chancroid, and that the latter should never, as a general rule, be ap- 
plied for this purpose except at the very commencement of the ulcer. 
Any one may convince himself of this truth by a comparative trial 
of the two agents. The same sore which continues to extend under 
the application of the nitrate of silver, will speedily cicatrize under 
the use of nitric acid repeated, if •necessary, every second or third 
aay. Any fears which might be entertained that the frequent ap- 



DESTRUCTIVE METHOD. 351 

plication of so powerful a caustic would do mischief appear to be 
groundless. 

The liquor hydrargyri pernitratis may be applied in a similar 
manner ; I am not aware, however, that it possesses any advantages 
over nitric acid, and it is attended with some danger of producing 
salivation. 

Potassa cum calce made into a paste and spread upon the chan- 
croid, where it is allowed to remain from five to fifteen minutes, is 
another convenient mode of applying the destructive method. 

Eicord has of late years employed a paste composed of vegetable 
carbon mixed with strong sulphuric acid. Its advantages are said 
to be that it forms a crust which closely adheres to the tissues, and 
does not fall off until the sixth or eighth day, when cicatrization is 
far advanced. I have used the carbo- sulphuric paste in a few in- 
stances, but not in a sufficient number to speak decidedly of its 
merits. Thus far, it has not appeared to me to be superior to other 
caustics, nor so convenient ; and it is, I think, little used etsewhere 
than at the Hopital du Midi. 

A valuable caustic, judging from the high encomiums bestowed 
upon it by many French surgeons, especially of the Lyons school, is 
to be found in " Canquoin's paste," composed of equal parts of chlo- 
ride of zinc and flour, wljich was first recommended for the destruc- 
tion of the chancroid by MM. Eollet and Diday. The finely- 
powdered chloride should be intimately mixed with an equal quan-* 
tity of flour, which has also been dried by heat, and alcohol added 
drop by drop until a paste is formed, which is to be spread in a thin 
layer upon cloth, and again subjected to gentle heat. Should 
deliquescence subsequently take place, the paste may readily be 
dried again without losing its caustic power. 1 When required for 
use, a disk corresponding in shape to the chancroid, and slightly 
exceeding it in size, is cut out and retained upon the surface, pre- 
viously cleansed of matter, from one to three hours, and in large or 
phagedenic ulcers for five or six hours. Two hours is the average 
duration required for ordinary cases. The patient should keep his 
bed until the paste is removed; and, since only one surface of the 
plaster is covered with caustic, the prepuce may be drawn forwards, 
when the sore is situated upon its internal surface, or upon the 
glans, without danger of injury to the sound tissues. 

The advantages of Canquoin's paste are its facility of application 
and freedom from the danger to which all liquid caustics are liable 

i Debattge, Traitement des Chancres Simples et. des Bubons Chancreux par la 
Cauterisation au Chlorure de Zinc; These de Paris, 1858, p. 12. 



352 CHANCROID. 

of involving the sound tissues ; the small amount of pain which it 
excites, and the possibility of graduating the depth of its destruc- 
tive action, which is directly proportioned to the length of the appli- 
cation. 

An improved formula is the following: — Take of dried chloride 
of zinc, two parts ; of flour, four parts ; and of glycerine, one part. 
Prepare the paste in the usual manner and roll it into a sheet three 
millimetres in thickness, which should be covered with a thick 
layer of flour and be exposed to the air for two days. ( Arch. Gen. 
de Med., March, 1863, p. 357.) 

But little dependence can be placed upon any therapeutic effect 
from the ingredients of the lotion or dressing applied to a chancroid. 
I do not mean to imply, however, by this remark that local treat- 
ment is unimportant. Neglect in this direction may result in 
decided injury ; while proper attention will put the ulcer in the 
most favorable condition for cicatrization to take place. If the 
secretion be allowed to accumulate and stagnate — if scabs be per- 
mitted to form under which matter may burrow, ulcerative action 
will be favored, and also successive inoculations in the neighbor- 
hood. These evils may be obviated by cleanliness, and by such 
form of dressing as will absorb or remove the pus as fast as it is 
secreted, assisted by astringents or disinfectants for the purpose 
either of hardening the surrounding surface or neutralizing the 
•virus. But this, I think, is about all that local applications can 
accomplish. To attribute to them specific virtues, as, for instance, 
to suppose that mercurial applications possess any power over the 
sore because it is a chancroid, is to my mind absurd. In short, 
topical remedies have the same influence upon a chancroid as upon 
simple ulcers, and do not affect its specific character. 

It is highly desirable to aim at simplicity in the local treatment 
of the chancroid ; though applications must be varied somewhat to 
correspond with the situation of the ulcer, and the copiousness of 
the discharge. 

Chancroids situated beneath the prepuce, when this fold of integu- 
ment habitually covers the glans, may be dressed with dry lint, 
which will be sufficiently moistened by the natural secretion of the 
part. It is often essential, however, for their speedy cicatrization, 
to effect their complete isolation from the natural secretion of the 
part, and this can only be accomplished by retracting the prepuce 
and dressing them as we would chancroids of the integument of the 
prepuce. In such cases, I am in the habit of using the following 
dressing : — I first apply to the sore a small piece of lint soaked in 



TOPICAL APPLICATIONS. 353 

some astringent lotion, cover this with a bandage wet in the, same 
fluid, and complete the dressing with oiled silk and a final retentive 
strip of muslin. Under this dressing, sores which for weeks have 
refused to heal will often take on speedy reparative action. No danger 
from oedema need be feared, provided the bandage be equably and 
not too tightly applied as far as the corona glandis. The dressing 
should be changed often enough to keep it moist. . 

Lotions are necessary when the sore is situated upon the external 
integument, in order to keep it moist and prevent the dressing from 
adhering to the surface, and this object may be still farther pro- 
moted by covering the dressing with oiled silk. 

In most cases, the lotion may consist of simple water or glycerine ; 
when medicated, such ingredients should, as a general rule, be added 
as will not leave a deposit or change the aspect of the sore, and thus 
render its condition obscure. The following formulae are among 
the best : — 

R. Liquoris sodae chlorinatae ^j. 

Aquae purse ^ij. 
M. 

R. Acidi nitrici diluti gj. 

Aquae purse ^viij. 
M. 

R. Vini aromatici ^j. 

Aquae giij. 
M. 

A formula for a convenient substitute for the French aromatic 
wine may be found on page 182. The strength of these lotions must 
be adapted to the sensibility of the part, which varies in different 
cases. They should never be so strong as to excite pain or produce 
irritation. 

The black wash, composed of from one to three scruples of calo- 
mel to four ounces of lime-water, is a favorite application with many 
surgeons. The dark-colored sediment in this mixture is an oxide 
of mercury, and is inert unless it affords mechanical protection to 
the sore. In my opinion, black wash is a less cleanly and less 
desirable lotion than those before mentioned. 

A solution of the potassio-tartrate of iron, in the proportion of 
from two to eight drachms of the salt to six ounces of water, is much 
employed by Eicord, especially in the treatment of phagedenic ulcers. 
In many cases this application acts very favorably ; while in others, 
I have found that the sore became covered with a dingy coating of 
coagulated matter, which obscured its condition, and required to be 

23 



354 CHANCROID. 

removed by a water dressing. I have only observed this unpleasant 
effect when the application has been made to sores beneath the pre- 
puce, and have been inclined to attribute it to a combination of the 
iron with the smegma prseputii. 

Lotions of acetate of lead are objectionable, since this salt is 
decomposed when brought in contact with the animal secretions, 
and an insoluble albuminate of lead, which is with difficulty 
removed, is deposited upon and incrusted in the tissues. 

Unguents are less desirable applications than lotions, and should 
only be employed when, from the position of the sore, or from the 
necessarily long intervals between the dressings — as at night or 
during a journey — the evaporation of a water dressing cannot be 
prevented, even with the assistance of oiled silk and glycerine. 
Mercurial ointment, which, as procured in the shops, is generally 
rancid or rapidly becomes so, is irritating and especially objection- 
able. One of the following formulae may be employed when an 
unctuous dressing is required. The first is much used in French 
hospitals. 

IJ. Cerati simplicis !|j. 

Tincturse opii gj. 

Calomelanos gr. xxxvj. 
M. 

R. Balsami Peruviani, 

Olei ricini, aa t ^j. 
M. 

R. Ung. zinci oxidi ^j. 

Pulv. opii 3J. 
M. 

The frequency with which local applications are to be changed 
must be determined by the copiousness of the secretion, which 
should not be allowed to collect and stagnate, or extend to the sur- 
rounding parts. 

Before one dressing is soaked with the discharge, another should 
be substituted. If the first adhere to the surface, it should be care- 
fully moistened before attempting its removal, in order to avoid any 
abrasion, which, by subsequent inoculation, would increase the size 
of the sore. The patient should also be directed not to cleanse the 
ulcer itself, but simply to remove the discharge from the neighbor- 
ing parts by touching them gently (without friction) with a soft 
piece of linen. The dressing of most uncomplicated chancroids 
need be renewed only two or three times a day, but phagedenic 
ulcers require a much greater frequency. 



TOPICAL APPLICATIONS. 356 

During the progress of cicatrization, exuberant granulations may- 
spring up and require repression by pencilling with a crayon of 
nitrate of silver. A superficial application of this agent is also 
beneficial in relieving the irritability and pain of some ulcers in the 
progressive and stationary periods. 

Other applications than those now mentioned may be required. 
For instance, in chancroids attended by much inflammation, leeches 
to the groins or perineum, and poultices or sedative lotions, are of 
service. Pain should be relieved by the exhibition of opium in 
large doses internally, and by its application externally. 



356 CHANCROID. 



CHAPTER II. 

SPECIAL INDICATIONS FROM THE SEAT OF CHANCROIDS. 

The seat of a chancroid often modifies the symptoms and necessi- 
tates changes in the treatment. 

Chancroids upon the Integument of the Penis. — Chancroids 
upon the integument of the penis often originate in a follicle, and 
when first noticed resemble a pustule or small abscess. Not unfre- 
quently they extend to the loose cellular tissue, and undermine the 
skin around a small external opening through which the pus can be 
made to well up on pressure. The movability of the integument 
over the concealed chancroid cavity interferes with cicatrization and 
prolongs the duration of the ulcer. The cavity, first thoroughly 
cleansed of matter, should be cauterized by means of a sliver of 
wood (as a lucifer match) dipped in strong nitric acid ; or sometimes 
it becomes necessary to enlarge the external opening even at the risk 
of inoculation of the edges of the wound. 

Chancroids of the Frsenum. — Chancroids of the fraenum are espe- 
cially painful, persistent, and exposed to hemorrhage. They may 
commence either upon the free margin or upon the base of the bridle. 
In the former case a rent or fissure, the result of violence during 
coitus, has probably been inoculated ; and the resultant chancroid 
gradually eats away the whole bridle, and hollows out a narrow 
longitudinal groove upon the under surface of the glans, giving 
great annoyance, persisting indefinitely, and resisting ordinary modes 
of treatment. Again, they may proceed from chancroids in the 
neighborhood, which exhibit a remarkable tendency to involve the 
bridle, if situated near it. In this case the base of the fraenum is 
first attacked, and often becomes perforated from side to side ; the 
chancroidal opening gradually enlarges, extends to the free margin, 
and, as in the former case, probably destroys the whole bridle. The 
fraenum is copiously supplied with blood, and exceedingly sensitive ; 
hence ulcers of this part are very liable to bleed and give rise to 



URETHRAL CHANCROIDS. 357 

much suffering. Their persistency and destructive tendency are due 
to the frequent rupture of the longitudinal fibres of the fraenum, 
occasioned by the constant motion to which it is exposed, in walking, 
handling the penis during micturition, in erections, etc. Minute 
rents are thus caused in the sore which become inoculated and in- 
crease its depth ; and ulcerative action goes on until the whole bridle 
is destroyed, including the portion buried in the under surface of the 
glans ; and hence the fossa already referred to. 

In the. treatment of these ulcers, the patient should be directed to 
avoid all motions of the part which will stretch the fraenum ; the 
glans should not be uncovered except to dress the sore, and even 
then no farther than is absolutely necessary to insert the dressing. 
If the chancroid threaten to destroy the whole bridle, time will be 
gained by accomplishing the same at once by means of caustic. 
When perforation has taken place, the remaining portion of the 
bridle should be divided with scissors, and the raw surfaces freely 
cauterized. The flow of blood in this operation is often troublesome, 
but may be avoided by previously passing a double ligature through 
the opening and tying each thread at either extremity of the frae- 
num, all of which should be removed. Diday heats one blade of a 
dull pair of scissors over a spirit lamp, and passing the opposite 
cold blade through the opening to serve as a support, thus divides 
the fraenum by the actual cautery. 1 

Urethral Chancroids. — As might be supposed, chancroids in 
the urethra are most frequently found near the meatus ; but they 
may be seated in any portion of the canal, and, in rare instances, 
even in the bladder. Eicord presented to the Academy of Med. of 
Paris 2 two specimens of phagedenic chancroid involving the deeper 
portions of the urethra and bladder, in each of which the disease 
had been recognized during life by the successful inoculation of the 
urethral discharge. 3 Yidal, with strange inconsistency, denies the 
possibility of these cases, and then reports a similar one of his own ! * 
Many chancroids of the fossa navicularis are visible on forced sepa- 
ration of the lips of .the meatus. For the purpose of exploring this 
portion of the urethra, I am in the habit of using Toynbee's ear- 
speculum, the uniform calibre of the extremity of which permits its 

1 Du Chancre Primitif du Frein de la Verge ; Gazette Hebdomadaire, Oct. 19, 1855, 
p. 749. 

2 Bull, de 1' Acad, de Med., 1838, t. ii., p. 506. 

8 These cases are figured in Ricord's Notes to Hunter. 

4 Treatise on Venereal Diseases, 1st Am. ed., N. Y., 1854, p. 209. 



358 CHANCROID. 

introduction for about an inch, and if the patient be placed in direct 
sunlight, an excellent view of the lining membrane for this distance 
may be obtained. 

When situated beyond the field of vision, urethral chancroids are 
recognized with greater difficulty, and may be entirely overlooked. 
The discharge is less copious than in gonorrhoea, and often streaked 
with blood ; pain is felt at a fixed point during micturition, and upon 
palpation along the course of the urethra ; inflammatory engorge- 
ment of the neighboring tissues can frequently be felt externally ; 
and there may be a suppurating bubo in the groin furnishing inocu- 
lable pus. The coexistence of gonorrhoea renders the diagnosis still 
more difficult, but even then the pain is especially severe at a fixed 
point of the canal during the passage of the urine. In doubtful 
cases, auto-inoculation of the urethral discharge may be relied upon 
as an unfailing test of the presence of this ulcer. ' 

Urethral chancroids, so near the meatus as to be visible, are to be 
treated in a similar manner to those situated externally ; the dress- 
ing, with a thread attached to facilitate its withdrawal, being inserted 
by means of a probe after each act of micturition. Deep urethral 
chancroids are not susceptible of much local medication. Injections 
of a solution of nitrate of silver have been recommended, but neither 
in this form, nor when the solid crayon is applied by means of Lal- 
lemand's instrument, can this agent destroy the specific sore. Topical 
applications must therefore be limited to injections containing opium, 
glycerine, or some mild astringent. Eelieve inflammation, if neces- 
sary, by leeches to the groin ; ;f abscesses form, open them early ; 
and, in all cases, guard against erections which tear and irritate the 
sore. 

Chancroids of the Female Genital Organs. — Upon the 
external and hairy surface of the labia majora, the chancroidal virus 
sometimes gains access to one of the hair follicles and gives rise to 
a follicular chancroid, which may readily be mistaken for a simple 
abscess. The most frequent seat of chancroids in women is at the 
posterior commissure of the vulva, where rents, which frequently 
occur from violent coitus, are readily inoculated in impure inter- 
course. A simple tear or fissure in this situation is very obstinate 
owing to the motion upon each other of the opposed surfaces and 
the exposure to irritation from the urine and vaginal secretions ; 
hence the diagnosis between a simple and virulent ulcer is often 
difficult, and in some instances can only be determined from the his- 



CHANCROIDS OF THE ANUS AND RECTUM. 359 

tory of the case, the condition of the inguinal ganglia, or from the 
results of experimental inoculation of the discharge. 

Chancroids of the deeper portions of the vagina cannot be treated 
by destructive cauterization, owing to the proximity of important 
parts — an objection which does not apply to those of the os uteri. 
The local applications employed in external chancroids may be 
made through a speculum. 

According to Gosselin, hypertrophy of the labia majora, whether 
accompanied or not by that of the labia minora and some of the 
carunculse myrtiformes, is so exclusively an effect of chancroids in 
the neighborhood of the vulva, that its presence is sufficient to justify 
the conclusion that a woman has at some previous time been thus 
affected. 1 

Chancroids of the Anus and Eectum. — Chancroids of the 
anus and rectum may occur in either sex from unnatural coitus, but 
are more frequent in women owing to the facility with which these 
parts are soiled with the secretion of sores situated upon the vulva. 
When seated upon the margin of the anus, they may readily be 
mistaken for fissures. They are attended by much pain, especially 
during the passage of the feces, which should always be rendered 
liquid before going to stool by a mucilaginous injection. It is 
sometimes advisable after clearing out the bowels, to thoroughly 
cauterize the sore, and to confine the patient to bed and a low diet, 
and administer opiates for the purpose of preventing any farthei 
stools until cicatrization has taken place. 

» Arch. Gen. de MeU, Dec. 1854, p. 684. 



360 COMPLICATED CHANCROID. 



CHAPTER III. 

THE CHANCKOLD COMPLICATED WITH EXCESSIVE INFLAMMATION 
AND WITH PHAGEDENA. 

Excessive inflammation terminating in gangrene gives rise to 
the inflammatory or gangrenous chancroid ; and phagedenic ulcera- 
tion, in several different forms, to as many varieties of the phagedenic 
chancroid. 

Inflammatory or Gangrenous Chancroid. — The inflamma- 
tion attendant upon a chancroid is sometimes so excessive as to 
terminate in gangrene, and produce a slough of the surrounding 
tissues, like that caused by the application of a powerful caustic. 
This complication is most liable to occur in cases of congenital or 
accidental phymosis, in which the sore is imprisoned beneath 
the prepuce. The extremity of the penis is very much swollen 
and oedematous, and often of a livid red color; a dark spot of 
commencing gangrene soon appears, generally upon the dorsal 
surface, and involves the prepuce to a greater or less extent ; the 
constricted portion, or glans, commonly suffers less than its covering; 
if the slough include all the tissues in the neighborhood of the 
chancroid, the latter, when the eschar is detached, presents the 
appearance of a simple wound, and — it is important to recollect — 
no longer secretes inoculable pus. The inflammation attendant upon 
chancroids complicated with paraphymosis may result in a similar 
manner. 

It is evident that excessive inflammation, which is generally 
induced by mechanical constriction, violence, want of cleanliness, or 
the abuse of alcoholic stimulants, is to be regarded merely as a 
complication of the original sore, and does not in itself change its 
nature. The transformation into a simple ulcer, finally induced in 
most cases by the supervention of this complication, is due solely to 
the fact that the tissues surrounding the ulcer are involved in the 
slough to an extent exceeding the sphere of specific influence of the 
virus. 



PHAGEDENIC CHANCROIDS. 361 

Inflammatory or gangrenous chancroids are included by most 
.English writers among the phagedenic, but there would appear to 
be sufficient reason to follow the classification adopted by the French, 
and consider them as distinct. Buboes are rare in connection with 
this variety. 

Inflammatory chancroids are to be treated by confining the patient 
to bed, low diet, mild purgatives, leeches to the groin or perineum, 
the local application of cold or evaporating lotions, and other anti- 
phlogistic measures, so long as the acute symptoms continue ; but if 
gangrene supervene tonics and stimulants are in most cases required. 
If the case be complicated with phymosis and the ulcer be concealed 
beneath the prepuce, the prepuce should be slit up by means of a 
bistoury carried along a director introduced from the orifice. If 
the slough of the tissues surrounding the ulcer has been complete 
there is no danger of inoculation of the edges of the wound ; but 
even when the gangrene is but commencing it is better to run the 
risk of inoculation than to incur the danger of an extensive loss of 
tissue from a large slough. 

Mr. William Lawrence, whose experience has been very extensive, 
has the following remarks upon the indications for an operation : — 
" To determine whether the prepuce should be divided or not is 
sometimes a difficult matter of diagnosis. The degree of redness, 
swelling, and pain, will not enable us to decide. The propriety of 
the measure depends on the condition of the sore which we cannot 
see. The discharge from the orifice of the prepuce must assist our 
judgment in doubtful cases. An ichorous or sanious state of dis- 
charge, with fetor, indicate sloughing; and in such circumstances the 
division ought to be performed. If the discharge should be puru- 
lent even though somewhat bloody, and the glans tender on pressure, 
we may be contented with leeches, tepid syringing, and mild aperi- 
ents." 1 Mr. L. believes the objection unfounded, that the cut edges 
may become inoculated with the virus, and take on phagedenic 
action. 

Phagedenic Chancroids. — In the chancroid, as commonly 
observed, the process of ulceration is generally slow and limited in 
extent, and advances with nearly equal rapidity in all directions; 
whence the sore maintains a rounded form, and does not involve the 
tissues to any great extent or depth. Phagedenic chancroids, on the 
contrary, are characterized by their more rapid, extensive, and 

1 Lectures on Surgery, London, 1863, p. 399. 



362 COMPLICATED CHANCROID. 

irregular progress ; though these characters vary greatly in degree 
in different cases. 

In the mildest and most frequent form of phagedena, the sore 
extends in surface and in depth beyond its ordinary bounds ; this is 
sometimes observed at all parts of the circumference, but generally 
at one part more than another, so that the circular form is lost, and 
the outline becomes irregular ; but yet the ulcerative action is not 
excessive. 

Phagedena may stop here, or go on to form a serpiginous chan 
croid, to the extent and duration of which there is no* limit. The 
edges of the sore in this variety are thin, livid, and cedematous, and 
so extensively undermined that they fall upon the ulcerated surface, 
or may be turned back like a flap upon the sound skin ; they are 
often perforated at various points, and are very irregular in their 
outline, resembling a festoon. The surface of the sore is uneven, and 
covered with a thick pultaceous and grayish secretion, through 
which florid granulations at times protrude, and bleed copiously 
upon the slightest touch. Serpiginous charlcroids are not attended 
by much constitutional reaction^ They exhibit a predilection for 
the superficial cellular tissue, and are inclined to extend in surface 
rather than in depth. They sometimes undermine the whole skin 
of' the penis as far as the pubes, or make their way down the thigh 
nearly to the knee, or upwards upon the abdomen, or follow the 
course of the crest of the ilium. They often advance on one side, 
while they are healing upon the opposite. Their progress may 
appear to be arrested, and the sore nearly cicatrized, when rapid 
ulceration again sets in and destroys the newly -formed tissue. Their 
secretion is copious, thin, and sanious, and preserves its contagious 
properties through the many years that the ulcer may persist. They 
leave behind them a whitish and indelible cicatrix, resembling that 
produced by a deep burn! 

This sore may be mistaken for the serpiginous ulceration of ter- 
tiary syphilis. It is distinguished from it by the fact that it com- 
mences with a chancroid — usually seated upon the genitals — or with 
a suppurating bubo in the groin ; that from this point of origin it 
extends by a continuous process of ulceration, the course of which 
is evident by the foul cicatrix which it leaves behind it ; and that it 
never overleaps sound portions of the integument. Moreover, the 
fluidity of its secretion does not favor the formation of scabs, and its 
contagious properties are manifest if inoculated upon the person 
bearing it. 1 

1 Bassereau, op. cit., p. 475. 



PHAGEDENIC CHANCROIDS. 363 

A third variety is called the sloughing phagedenic ulcer, and is 
characterized by the greater acuteness of the destructive action. Its 
symptoms closely resemble those of hospital gangrene. There is 
considerable constitutional disturbance, a full and hard pulse, furred 
tongue, and other symptoms of inflammatory fever. The pain is 
often excessive, and almost insupportable. The ulcer extends chiefly 
to dependent parts in the neighborhood, which are infiltrated by its 
copious and foul secretion. It respects no tissue whatever, and its 
ravages are sometimes terrible ; the glans, penis, or labia may be 
wholly destroyed, and the testicles entirely laid bare. Fatal hemor- 
rhage has been known to occur from ulceration of the arteria dor- 
salis penis. The sloughing phagedenic chancroid is most common 
among the intemperate and lowest class of prostitutes, and also 
among persons visiting hot climates and exposed to various hard- 
ships. It was this variety which decimated the English troops in 
the Peninsular war, although venereal diseases were comparatively 
mild among the natives. 

■Phagedenic chancroids are not unfrequently attended by buboes, 
which generally take on the same destructive action as them- 
selves. . 

Fournier's confrontations, already referred to, prove that the 
phagedenic chancroid is not always transmitted in its kind, and that 
hence it cannot depend upon a distinct species of virus. It does 
not, however, conflict with this statement to admit that contagious 
matter may possess noxious properties independent of the contained 
virus, but capable of exciting a severe form of ulcerative action. 
This appears not improbable when we consider that vaccine lymph 
which is derived from unhealthy tissues or allowed to stand in 
solution until it becomes putrid, may develop such a degree of 
inflammation as to prove fatal. Witness the mortality in the town 
of Westford, Mass., in the spring of 1860, following vaccination 
with scabs originally pure, but which were dissolved in water and 
exposed to air and heat until they were decomposed. 1 In most 
cases, however, phagedena is doubtless dependent upon some form 
of constitutional cachexia, the exact nature of which is not always 
apparent. The abuse of mercury in the treatment of venereal ulcers 
is another cause, which was more frequent a few years since than 
now ; and the improved practice of the present day may account in 
a measure for the partial disappearance of this variety. 

The general treatment of phagedenic ulcers should be based upon 

1 Boston Medical and Surgical Journal, May, 18G0. 



36i COMPLICATED CHANCROID. 

a knowledge of the cause of the destructive action when this can be 
ascertained. Phagedena most frequently occurs in persons debilitated 
by various causes, as intemperance, irregularity of life, want, or a 
residence in damp, unhealthy apartments ; in these cases, nourishing 
food, the ordinary comforts of life, and the mineral or vegetable tonics 
are required. Scrofula is another fruitful source of phagedena, and 
calls for preparations of iodine and other antistrumous remedies. 
Moderate doses of opium repeated at short intervals, so as to keep 
the patient gently under its influence, are often of essential service 
in allaying pain, and in controlling the progress of the disease. 
Numerous observers have called attention to the beneficial effect of 
this agent upon ulcerative action, and have ascribed to it a decidedly 
tonic influence. Kodet reports several cases of serpiginous chan- 
croids which resisted a great variety of means, but which yielded to 
opium. This surgeon commences with about one grain of the gummy 
extract of opium morning and night, and gradually but rapidly in- 
creases the dose so that the system may not become habituated to it 
before its therapeutic effect takes place. He prefers two large doses' 
in the twenty-four hours to smaller ones more frequently repeated, 
in order that digestion may go on unimpeded in the intervals. Light 
wines are largely administered at the same time, and are said to cor- 
rect any tendency to constipation. 

In many cases it is impossible to discover the cause of phagedena. 
The general condition of the patient is good ; all his functions are 
duly performed; and yet his ulcer continues to extend. In such 
cases our chief reliance must be placed upon deep cauterization, and 
the general treatment must be more or less experimental. 

The potassio-tartrate of iron is a remedy of great value in phage- 
denic chancroids, when a tonic is required. Ricord calls this prepa- 
ration the " born enemy" of phagedena, and attributes to it an almost 
specific influence upon ulcerative action. I can add my own testimony 
to that of Ricord and many other surgeons in its favor, and would 
strongly recommend a trial of it in the class of cases under consid- 
eration. 

R. Ferri et potassse tartratis 33s. 

Aquae 3"iij. 

Syrupi ~iij. 
M. 

From two teaspoonfuls to a tablespoonful of this solution may be 
taken three times a day, within an hour after meals, and a lotion 
containing the same salt be applied to the ulcer. 

The chief means, however, for the cure of phagedenic chancroids 



GENERAL TREATMENT. 365 

is to be found in the complete destruction of the sore by a powerful 
caustic or the actual cautery. In cases of a comparatively mild, 
character, we may rely upon frequent applications of fuming nitric 
acid, taking care to apply it to every crevice, especially beneath the 
edges of the undermined integument. If the smallest loophole be 
left from which virulent pus can proceed, it will inoculate the wound 
remaining after the fall of the eschar, and the only effect of the treat- 
ment will be to increase the size of the ulcer. It is evident, there- 
fore, that cauterization, in order to be a benefit and not an injury, 
must be thorough and completed In severe cases Eicord repeats the 
application as often as twice a day ; and in the meanwhile dresses 
the sore with lint soaked in aromatic wine or a solution of the po- 
tassio-tartrate of iron. Pain and swelling are not always contra-in- 
dications to the use of the caustic, which is frequently the most 
effective sedative that can be employed. Eobert states that cauteri- 
zation with the carbo-sulphuric paste has been very successful in his 
hands. I would suggest a trial of the local application of bromine, 
which has recently proved so successful in the treatment of hospital 
gangrene; 

Just as these pages are going to press, I learn that a solution of 
the permanganate of potassa, which is claimed to be superior to 
bromine in the treatment of hospital gangrene, 1 has been employed 
at the N. Y. Hospital with great success, as a local application to 
sloughing phagedenic chancroids, in three cases. A saturated solu- 
tion (gr. lxxxv. ad aquas gj) was applied every two hours, and the 
sores dressed between the applications with lint soaked in a mixture 
containing a drachm of the saturated solution to a pint of water, until 
the surface of the ulcers cleared off, when the dressing was alone 
continued. The pain of the application was not severe, and in each 
instance reparative action was set up in the course of from twenty- 
four to forty-eight hours. This agent is certainly worthy of farther 
trial. 

In the more severe cases of phagedena, as in serpiginous and 
sloughing chancroids, when other means have failed, it becomes ne- 
cessary to resort to a more powerful destructive agent than any of 
the ordinary caustics. Some hesitation may be felt in applying the 
actual cautery to so extensive a surface as is often covered by these 
ulcers ; but when the gravity and obstinacy of the disease are con- 
sidered, it must be confessed that almost any means is justifiable 
which holds out a fair promise of cure. 

i See an article entitled : Remarks on the Use of Permanganate of Potassa, Dy 
Dr. F. Hinkle ; Am. Med. Times, Nov. 28, 1863. 



366 COMPLICATED CHANCROID. 

The patient should be rendered insensible by means of an anaes- 
thetic, and the cauterizing irons of different shapes and sizes be raised 
to a white heat. 

Eollet directs that the ulcer should first be cleansed by washing 
it copiously with water, removing all adherent matter and then dry- 
ing it. Every portion of the secreting surface should now be deeply 
cauterized, carrying the hot iron into every nook and sinus, and 
paying special attention to the parts overlapped by the skin of the 
edges. These flaps of integument should be cauterized not only 
upon the under, but also upon the outer surface, so as to be for the 
most part destroyed. A cold water-dressing is afterwards applied, 
and the patient, on waking, does not suffer much more than he did 
before the operation. When suppuration commences, Goulard's 
extract or aromatic wine may be added to the lotion. Eollet has 
recently reported two cases of success by this method. 1 

An attack of erysipelas has been known to arrest the progress of 
phagedena and to induce cicatrization of serpiginous ulcers which 
had proved intractable under almost every form of medication. An 
instance of this kind is contributed by M. Buzenet to Eicord's Lemons 
sur le Qhancre, and several are reported by other surgeons. 

1 Note sur la Destruction du Chancre Phage"d6nique Serpigineux par la Cauteriaa- 
tion Actuelle ; Annuaire de la Syphilis, 1858, p. 116. 



COMPLICATED CHANCKOID. 367 



CHAPTER IV. 

THE CHANCROID COMPLICATED WITH SYPHILIS. - 
"MIXED CHANCRE." 

Syphilitic infection of the system presents no barrier to the 
existence of a chancroid, and vice versd. Universal experience con- 
firms the statement that a person presenting syphilitic symptoms, 
whether primary, secondary or tertiary, may contract a chancroid, 
which will run the same course as in a person free from syphilis. 
Moreover two inoculations, one with the chancroidal and the other 
with tho syphilitic virus, may occur side by side, and the resultant 
chancroid and chancre will each pursue its normal course unin- 
fluenced by the neighborhood of the other ; and, finally, two such 
inoculations may take place at one and the same point and produce 
a sore possessing all the properties of the chancroid and the primary 
syphilitic ulcer, viz. : on the one hand, auto-inoculability and the 
power of producing a suppurating bubo secreting inoculable pus ; 
and on the other, an indurated base, induration of the neighboring 
ganglia, and a secretion capable of communicating syphilis to a 
person free from previous syphilitic taint. 

I have denominated such a sore a " chancroid complicated with 
syphilis." It would clearly be just as appropriate to call it " primary 
syphilis complicated with the chancroid." The French have named 
it the "mixed chancre." The implantation of the two kinds of 
virus may take place synchronously, as, for instance, in the same 
act of coitus when a man has connection with a woman affected with 
a chancroid and also with syphilitic manifestations ; or the inocula- 
tion of either virus may occur upon a previously existing ulcer of 
the opposite species. In either case, when once developed, the 
mixed chancre may be perpetuated in its kind by successive inocu- 
lation from one individual to another. 

The following instance in which a mixed chancre was developed 
by the inoculation of a primary syphilitic ulcer with the chancroidal 
virus, is reported by Fournier : — 



368 COMPLICATED CHANCROID. 

Alphonse N., aged 17, contracted a chancre in the latter part of 
Sept., 1857. He became an out-patient of the Hopital du Midi, Oct. 
3, when a chancre, surrounded with cartilaginous induration, was 
found in the fossa behind the corona glandis, and the glands in both 
groins were enlarged, hard, and indolent. A dressing with aromatic 
wine was ordered for the sore, and mercury internally. 

Oct. 14. The chancre has entered upon the period of repair; it is 
less excavated, and its edges less prominent. 

Oct. 24. There has been a change for the worse. The original 
chancre has increased in surface and in depth ;. its base is still very 
much indurated. Moreover, upon the skin of the penis is found 
another large ulcer; its base ©edematous, but without true induration. 
There are also several small ulcers with soft bases upon the external 
surface of the prepuce. The patient declares most positively that he 
has had no sexual connection since he contracted his first chancre. 
Are the recent sores to be attributed to accidental inoculation from 
the first ? 1ST. is this day admitted as an in-patient. 

In the early part of JSTov. one of the lymphatic ganglia in the left 
groin became acutely inflamed, and presented all the characters of a 
bubo dependent upon a chancroid. It suppurated, and its pus was 
inoculated with success. In the right groin, the enlargement and 
induration of the ganglia characteristic of a chancre remained as 
before. 

In Dec. secondary symptoms appeared; roseola and multiple 
mucous patches. 

In spite of the patient's denial, Eicord attributed the more recent 
ulcers to a second exposure and fresh contagion ; and a few days 
after his entrance into the hospital, the patient privately confessed 
to M. Fournier, the Interne, that on Oct. 15th he had connection with 
a woman whose name and address he gave. He also stated that on 
the following day his first ulcer began to enlarge, and the others 
appeared two days after. 

Fournier immediately visited the woman indicated by N., and 
found that she had three large chancroids with perfectly soft bases, 
situated upon the internal surface of the left labium, on the four- 
chette and upon the folds at the entrance of the vagina, and of about 
three weeks' duration. The inguinal ganglia were in a normal 
condition. 

This woman also confessed to M. Fournier that she had infected 
her lover, Charles V., who, by a singular coincidence, was at that 
moment a patient in the Hopital du Midi, and who likewise had 
several chancroids with soft bases upon the prepuce and an acute 
bubo in the left groin. 

To sum up this history: a man with a primary syphilitic ulcer in 
the period of repair and an indolent indurated bubo has connection 



cases. 369 

with a woman affected with chancroid. He contracts fresh nlcers 
which prove to be chancroids, and one of which is seated upon the 
surface of the original chancre. An inflammatory bubo appears, 
which suppurates & d furnishes inoculable pus. Finally, symptoms 
of general syphilis are developed. 1 
Eollet relates a si.nilar case : — ■ 

G. Francois, aged 20, entered the Antiquaille Hospital, at Lyons, 
with a sore situated upon the meatus, and which was slightly indu- 
rated and presented the usual aspect of a chancre. The fossa at the 
base of the glans was also studded with several ulcers which were as 
soft as possible. The ganglia in the groin were indurated. In six 
weeks after exposure, the patient was attacked with headache, 
syphilitic roseola, and rheumatic pains. 

In order to confirm the diagnosis as to the nature of the sores, 
Eollet inoculated matter from the one which was indurated upon the 
left thigh, and the secretion of the others upon the right. The 
result was positive in both. It was then thought that pus from the 
simple sores might have been deposited upon the indurated one, and 
thence taken up upon the lancet. Eollet therefore waited until the 
chancroids in the fossa behind the corona had completely healed, and 
then, after repeatedly cauterizing the indurated sore with solid 
nitrate of silver, inoculated its secretion a second time. This inoc- 
ulation produced the characteristic pustule of a chancroid as before ; 
thereby showing that the success of the first inoculation was not 
owing to the presence of matter which had been simply deposited 
and again taken up, but to the inherent properties in the secretion 
of the sore itself. 2 

M. Eollet and his Interne, M. Laroyenne, were led by this case to 
try the effect of inoculating chancres with matter from a chancroid. 
Their experiments are briefly related as follows : 

Case 1. Pieri M. ; indurated chancre of the meatus ; duration three 
weeks; indurated ganglia; inoculation of the secretion of the chan- 
cre, negative. Sept. 14, the pus of a chancroid was deposited upon 
the sore. Sept. 15, application of the solid nitrate of silver ; lotions ; 
dressing with aromatic wine. Sept. 19, second inoculation; chan- 
croidal pustule. 

Case 2. John L. ; indurated ulcer almost healed ; indurated gan- 
glia; general treatment and local application of aromatic wine; 
inoculation negative. Nov. 18, pus from a chancroid is applied to 

1 Lemons sur le Chancre, p. 119. 

2 Laroyenne, Etudes Experimentales sur 'e Chancre, Annuaire de la Syphilis, 
annSe 1858, p. 248. 

24 



370 COMPLICATED CHANCEOID. 

the ulcer; treatment continued. Nov. 23, second inoculation; this 
time positive. 

Case 3. Eobert M. ; parchment variety of chancre upon the skin 
of the penis; duration five days. Dec. 11, inoculation without 
result ; dress with opiated cerate and calomel. Dec. 16, application 
of the virus of a chancroid. Dec. 17, same dressing. Dec. 22, inoc- 
ulation positive. 

Case 4. Peter M. ; chancre of six weeks' duration, occupying three- 
fourths of the circumference of the fossa glandis. Dec. 11, inocula- 
tion unsuccessful. Dec. 16, application of the virus of a chancroid. 
Dec. 17, dress with opiated cerate with addition of calomel. Dec. 
22, inoculation successful. 

According to Eollet, two or three days after the application of 
the virus of a chancroid to a chancre, the sore assumes a grayish, 
aspect like an ordinary chancroid, but is less excavated ; its edges 
become jagged, and its purulent secretion more copious and sanious; 
it may give rise to successive chancroids in the neighborhood or to 
a virulent bubo. It preserves, however, the essential characters of 
a chancre, and, among others, induration of its base, which is always 
pathognomonic ; the ganglia of both groins are indurated as usual, 
unless a virulent bubo supervenes, when those of the opposite side 
may still indicate the nature of the disease. The general symptoms 
following the chancre are not modified by this inoculation, and 
secondary symptoms appear at the same time and in the same 
manner as under ordinary circumstances. The more copious secre- 
tion of the chancroid renders this species more liable to be ingrafted 
upon a chancre than the latter upon the former. 

Thus far we have supposed the inoculation of one species of virus 
to succeed that of the other, but both sometimes, though rarely, 
occur during the same act of coitus. In this case the chancroid, 
which has no period of incubation, is first developed in its usual 
form, with abrupt edges, grayish floor, and soft base ; subsequently 
the chancre appears, when the base of the sore and the neighboring 
lymphatic ganglia become indurated. If, as is probably true, those 
chancres which are auto-inoculable belong to the mixed variety, we 
may obtain some idea of their frequency from the inoculations of 
Eicord, Fournier, Puche, and others ; about two per cent, of which 
have been successful. Kollet's observations make the ratio about 
five per cent. Eollet is inclined to believe that the ulcer which has 
been described by Carmichael, Eicord, and Eoyer as the "ulcus 



MIXED CHANCKE. 371 

elevatum," is a mixed chancre, which generally shows a tendency 
to become elevated above the surrounding surface. 1 

The union of the two species of virus in this variety is analogous 
to the mixture which takes place when gonorrhoea is complicated 
with urethral chancre, constituting the only true " gonorrhoea viru- 
lenta ;" and also to the union of either the chancroidal or syphilitic 
virus with that of vaccinia, of which a number of examples are 
recorded. 

The mixed chancre requires the local treatment of the chancroid 
and the general treatment of syphilis. 

1 Rollet, De la Plurality des Maladies Vene'riennes ; Gaz. M6d. de Lyon, No ", 
1860. 



372 BUBOES. 



CHAPTER V. 

BUBOES. 

Bubo, derived from the Greek "£ou,£wv, the groin," etymologically 
bignifies any tumor of the inguinal glands ; and the term has also 
been applied to glandular swellings of other parts of the body, as 
the axilla, neck, etc. Many affections, distinct in their nature and 
origin, have thus been confounded under a common name, which, 
unless limited by some qualifying epithet, conveys but a very vague 
meaning. As generally employed, however, the term bubo signifies 
an affection of the lymphatic ganglia of venereal origin ; and I 
would still farther limit its application to those venereal affections 
of the ganglia which are attended by symptoms of inflammation 
and which frequently terminate in suppuration ; thus excluding the 
" induration of the ganglia " which accompanies a primary syphilitic 
ulcer. 

In the great majority of cases buboes are dependent upon the 
presence of a chancroid ; but they may also be caused by a gonor- 
rhoea or by excessive venery. They are never due to uncomplicated 
balanitis. A primary syphilitic sore, or chancre, is accompanied by 
induration of the ganglia, which never suppurate unless under the 
influence of some additional exciting cause. The occurrence of 
buboes is favored by a strumous constitution, by irritant applications 
to a chancroid, by mechanical violence, undue exercise, excesses in 
diet, and by sexual intercourse during the existence of a chancroid 
or gonorrhoea. Men are much more exposed to them than women. 
It has been estimated that 40 out of every 100 men with chan- 
croids are attacked with buboes; and of these 40, that from 30 to 35 
have suppurating buboes ; while of every 100 women affected with 
chancroids, only 20 have acute inflammation of the ganglia, of which 
15 suppurate. 1 The influence of the virus of a chancroid upon the 
ganglia is limited to those which are nearest the ulcer in the course 

1 Notes of Prof. Zeissl's lectures, 1862-3, for which I am indebted to Dr. E. T. 
Caswell, of Providence, R. I. 



SIMPLE INFLAMMATORY BUBO. 373 

oi the lymphatic circulation ; and it is always the superficial, and 
never the deep ganglia which are affected. 

Buboes may be divided into, 1st, the simple inflammatory bubo, 
2d, the virulent bubo, and, 3d, the indolent bubo. The first two are 
characterized in common by symptoms of acute inflammation. They 
differ in that the first is capable of resolution, but, when terminating 
in suppuration, secretes simple pus; while the second, dependent 
upon absorption of the chancroidal virus, necessarily sujrpurates 
and furnishes inoculable pus. The indolent bubo, as its name in- 
dicates, is marked by its subacute character, and, as it most fre- 
quently occurs in strumous subjects, is sometimes called the " stru- 
mous or scrofulous bubo." 

Simple inflammatory bubo. — This is also known as the " sym- 
pathetic " bubo, — a term employed to denote a relationship, as cause 
and effect, between a gonorrhoea or chancroid and the inflammation 
of the ganglion, but the exact nature of which relationship is not 
always apparent. We may suppose that in some instances irritant 
matter is conveyed along the lymphatics, or that common inflamma- 
tion traverses the course of these vessels ; or that an unknown sym- 
pathy or bond of union exists between the surface and the corre- 
sponding ganglion, whereby disease of the one produces morbid 
action in the other. This explanation of the origin of inflammatory 
or sympathetic bubo is confessedly unsatisfactory, but is the best 
that can be given in the present state of our knowledge. Analogous 
instances are found in the inflammation and suppuration of glands 
in other parts of the body, as the axilla, in consequence of wounds 
of the fingers, excessive manual labor, prurigo, eczema, etc. 

The symptoms of simple adenitis are well known. Most fre- 
quently only one gland is affected ; if others are involved, they are 
commonly so to a less degree. The patient first notices a swelling 
in the groin attended with tenderness on pressure, and pain which 
is aggravated by motion or the standing posture. The gland is felt 
to be somewhat enlarged, but is still movable beneath the integu- 
ment which preserves its normal color ; and the surrounding cellular 
tissue is evidently thickened by infiltration. This condition may 
last for an indefinite period — during the continuance of the ulcer or 
even after its cicatrization, and yet finally disappear without suppu- 
ration. 

In less fortunate cases, the inflammatory symptoms increase in 
severity ; the tumor acquires larger dimensions and becomes adherent 
to the skin and underlying fascia so that it is no longer movable ; 



37-i BUBOES. 

the pain and tenderness are increased ; motion is difficult ; the skin 
becomes reddened ; suppuration is ushered in by a chill ; the presence 
of matter is indicated by a soft spot in the midst of the general 
hardness and soon after by distinct fluctuation ; and although reso 
lution is still possible, yet commonly the contents of the abscess are 
discharged through an opening in the integument formed by the 
process of ulceration. In the great majority of cases I believe that 
the seat of the suppuration is in the cellular tissue surrounding the 
gland and not in the gland itself. The original congestion or in- 
flammation of the glandular tissue appears to undergo resolution 
after exciting a similar process in the loose cellular tissue of the 
neighborhood which more readily takes on suppurative action ; and 
when the abscess is opened by nature or art, the gland may often be 
seen within the cavity already covered with granulations destined 
to commence the work of repair. 

I have spoken of the simple inflammatory bubo as affecting one 
ganglion, but it sometimes happens that two or more are involved, 
when several collections of matter may form, which by their early 
union may give rise to one large abscess ; or they may remain dis- 
tinct or only communicate after the opening of one of them. Not 
unfrequently these collections of matter are separated by Poupart's 
ligament, one being situated in the groin and the other upon the 
upper and inner part of the thigh. 

The course of a bubo subsequent to the evacuation of the con- 
tained matter varies in different cases. In healthy subjects and 
under proper treatment, the cavity may rapidly contract and fill 
with granulations, its walls unite and cicatrization take place, leaving 
a slight scar scarcely perceptible after the lapse of a few months. 
In less fortunate cases, secondary abscesses form in the neighbor- 
hood even after the first has been . opened, and communicating with 
the cavity of the latter, give rise to fistulous passages which are 
often several inches in length. Or, again, instead of having a dis- 
tinct point of origin, a fistulous track may shoot out from the cavity 
itself. The opening may have been free, allowing ample exit to the 
matter, and the process of repair appear to be going on propitiously, 
when suddenly without apparent cause the surgeon in passing his 
finger over the surface notices a hardened chord beneath the skin, 
or in probing the cavity discovers a new fistulous track, which has 
formed insidiously without giving the slightest indication of its 
presence. In short, a line of infiltration of the cellular tissue has, 
as it appears, started from the original abscess, and by a process of 
suppuration opened a new fistulous track ; and thus the cellular 



VIRULENT BUBO. 375 

tissue beneath the skin may become riddled with false passages of 
various lengths and running in various directions, and which remind 
one of the burrowings of a mole in a hay-field. In whichever mode 
developed, these fistulous tracks most frequently run along Pou- 
part's ligament either upwards and outwards towards the anterior 
superior spine of the ilium, or downwards and inwards to the inner 
fold of the thigh. In rare instances they penetrate nearly perpen- 
dicularly to the surface for some distance. Their walls become 
covered with a kind of false membrane which secretes a thin puru- 
lent matter, and the surrounding tissues are more or less brawny to 
the touch. 

Virulent Bubo. — The virulent bubo receives its name from the 
fact that the pus which it contains is contagious, and will, upon 
artificial inoculation, give rise to a chancroid. 

A virulent bubo may form either at an early or late period of 
the existence of a chancroid. M. Puche reports a case in which it 
first made its appearance three years after the commencement of a 
serpiginous chancroid. 1 

A virulent bubo is due to the absorption of virus from the sur- 
face of a chancroid, and its conveyance by means of the lymphatics 
to the ganglion ; here its farther progress is arrested in the intricate 
meshes and minute ramifications of this body, and its presence gives 
rise to inflammation which assumes the specific character of the 
exciting cause. The same power of reproduction is manifested 
which gives to virulent pus its contagious qualities, and the abscess 
which necessarily ensues is filled with inoculable matter. Kesolu- 
tion is as impossible and suppuration as inevitable as if the secre- 
tion of the chancroid had been deposited within the ganglion upon 
the point of a lancet. 

Virulent adenitis is usually situated upon the same side as the 
chancroid, but sometimes upon the opposite, owing to the interlace- 
ment of the lymphatic vessels upon the dorsum of the penis. Some- 
times both groins are affected, especially when the ulcer is situated 
upon any part in the median line, as the frsenum. It is very rare 
for more than a single gland on one or both sides to suppurate 
specifically; and hence the virulent bubo is said to be "mono- 
ganglial." Other ganglia in the neighborhood may, however, be 
secondarily affected through sympathy or extension of the inflam- 
matory process, but should they suppurate, the pus is not inoculable 
like that of the first ganglion. 

1 Ricord, Leijons sur le Chancre, p. 40. 



376 BUBOES. 

Prior to its spontaneous or artificial opening, the conrse of a 
virulent is the same as that of a simple bubo, and the student should 
understand that the early symptoms of the two are identical ; though 
the distinction between them is fully justified by the inevitable sup- 
puration and specific properties of the one, and the possible resolu- 
tion and simple character of the other. 

During the formation of this bubo, the virulent pus is confined to 
the interior of the affected ganglion ; but at the same time simple 
inflammation and suppuration are going on in the surrounding cel- 
lular tissue as in the simple inflammatory bubo, and hence there are 
two collections of matter separated by the wall of the ganglion ; the 
one within containing chancroidal, and the one without simple pus. 
Now if the bubo be left to itself, the external abscess commonly 
breaks before the internal, and consequently the pus which first 
flows out is simple and not inoculable, and the cavity of the abscess 
may be covered with healthy granulations like that of the simple 
inflammatory bubo. In the course of a few days, however, the 
glandular abscess discharges its virulent matter which inoculates 
the surface of the cavity, and the latter puts on all the characters 
of a chancroid ; its interior becomes covered with a grayish diphthe- 
ritic deposit, its edges are everted and undermined, and its secretion 
is auto-inoculable, or if it accidentally comes in contact with any 
solution of continuity, as a leech bite, in the neighborhood, it will 
give rise to a chancroid. The same can be demonstrated when open- 
ing the bubo artificially ; if a superficial incision first be made so as 
to penetrate the external abscess only, and a drop of the exuding 
matter be inoculated; and if subsequently the knife be made to 
penetrate the glandular abscess, and some of its contents be also in- 
serted beneath the epidermis, it will be found that the former inocu- 
lation will fail while the latter will succeed. 1 

Secondary abscesses may form in the vicinity of the gland first 
affected in the virulent, the same as in the simple inflammatory bubo, 
but virulent pus does not appear in them except as the result of 
inoculation from the original abscess. Again, fistulous passages 
may be produced in the manner already described. If the chancroid 

1 "Equally instructive examples (that the glands collect hurtful ingredients, and 
thereby afford protection to the body) are afforded by the history of syphilis, in 
which a bubo may for a time become the depository of the poison, so that the rest 
of the economy is affected in a comparatively trifling degree. As Ricord has shown, 
it is precisely in the interior of the real substance of the gland that the virulent 
matter is found, whilst the pus at the circumference of the bubo is free from it; only 
so far as the parts come into contact with the lymph conveyed from the diseased 
part, do they absorb the virulent matter." (Virchow, Cellular Palhology, p. 187.) 



INDOLENT- BUBOES. 377 

upon the genitals be complicated with phagedena, the open bnbo 
generally follows the same course ; and hence arise those extensive 
and foul chancroidal ulcerations of the groin which are occasionally 
seen in hospitals, and which are depicted in nearly all illustrations 
of venereal diseases. 

Indolent Bubo. — One or more ganglia, seldom exceeding two or 
three, are commonly involved in the indolent or scrofulous bubo. 
The subacute character of the inflammatory process is the chief 
characteristic of this form of bubo, which closely resembles the well- 
known strumous inflammation of the glands of the neck in children. 
The inguinal tumor is less firm and of a more doughy feel than in 
the buboes above described. A moderate amount of pain, tender- 
ness on pressure, and difficulty of motion, may be complained of by 
the patient, but these are rarely severe or of long continuance. The 
tumor very slowly enlarges, perhaps to the size of a hen's-egg, and 
loses its mobility in consequence of contracting adhesions to the 
neighboring tissues. The skin covering it becomes thin and of a 
livid red color, and fluctuation can be detected without being ushered 
in by chills and fever, as in the inflammatory bubo. If an opening 
now be made with the lancet, the young surgeon is surprised to find 
that nothing resembling ordinary pus flows out, but merely a thin, 
flaky, watery-looking fluid. If, on the other hand, the tumor be left 
to itself, several openings usually form spontaneously at different 
points of the surface, and the skin included between them, being 
deprived of its vascular supply, loses its vitality and gives way. 
The glands thus exposed are found to be more or less disorganized ; 
they are of a spongy and friable texture, and infiltrated with thin 
purulent matter which can be made to exude upon pressure from the 
numerous openings upon their surface. The external opening is 
still farther enlarged by retraction of the skin, and the mass of 
swollen and disorganized glands often projects above the level of 
the surrounding integument, and, acting like a foreign body, inter- 
feres with cicatrization of the wound. Fistulous tracks may form, 
running in various directions, as in the inflammatory and virulent 
buboes ; and gangrene or phagedena may set in, giving rise to ex- 
tensive, foul, and obstinate ulcerations, and attended with great rest- 
lessness, anxiety, a small and frequent pulse, a dry and coated tongue, 
and other symptoms of general depression. The indolent bubo is 
frequently met with in private practice, but the complications just 
mentioned are rare, except among the lower classes who frequent 
our charity hospitals. 



B78 BUBOES. 

Tbe older writers on venereal admitted the existence of a so-called 
"bubon d'emblee" or " non-consecutive bubo," arising independently 
of any lesion of the genital organs, secreting inoculable pus, and 
attended by syphilitic infection of the constitution, and which, as 
was supposed, was due to absorption of the syphilitic virus through 
the sound integument without local reaction at the point of infection. 
The admission of such a bubo as this is entirely inconsistent with 
the present state of our knowledge. It is indeed true that buboes 
sometimes occur without any appreciable lesion of the genitals, but 
they belong either to the simple inflammatory or indolent forms 
above described, and, as stated by Eicord, " are occasioned by sym- 
pathetic reaction consequent upon irritation of the extremities of 
the absorbents during coitus, as may occur after any non-specific 
excitation of the part." A bubo secreting inoculable pus can depend 
only upon a chancroid situated either externally or concealed within 
a mucous canal, as the urethra, vagina, or rectum ; and syphilitic 
infection of the system cannot take place without a chancre appear- 
ing at the point of inoculation. Diday, who has especially studied 
the bubo arising under the circumstances mentioned, assigns to it 
the following characteristics : ! 

1. A long period of incubation, which is usually of about three 
weeks' duration. 

2. A few days before the appearance of the bubo, the patient 
suffers from general disturbance of the system, inability to sleep, 
heat and dryness of the skin, irregular chills, lassitude, loss of ap- 
petite, and pain in the lumbar region. These symptoms precede 
rather than follow the evolution of the bubo, do not correspond with 
it in intensity, and diminish as it progresses. 

3. The inflammation is always subacute. The tumor is slow in 
forming; the pain and sensibility are slight; and if suppuration 
take place, the skin does not become reddened nor matter form in 
the surrounding cellular tissue, as almost invariably occurs in viru- 
lent adenitis. 

4. It is of long duration, and under the most favorable circum- 
stances generally persists for at least a month. 

5. It suppurates in about one case out of every four ; but the open- 
ing of the abscess is never transformed into a chancroid, and the pus can 
never be artificially inoculated. 

6. Constitutional syphilis never follows when this has been the only 
wmereal symptom. 

1 Nouvelles Doctrines sur la Syphilis, p. 186. 



TREATMENT OF BUBOES. 370 

Treatment of Buboes. — The pbjects to be attained in the treat- 
ment of buboes are, to subdue inflammation and avert suppuration, 
if possible ; or, if not, to hasten the cicatrization of the ensuing 
abscess. 

When the bubo is virulent and specific pus is imprisoned within 
the ganglion, all attempts to effect resolution will certainly fail ; but 
as this species cannot, at an early period, be distinguished from a 
simple bubo — although the presence of a chancroid upon the 
genitals may lead us to suspect it — we cannot in practice discrimi- 
nate these cases, and must treat all inflammatory buboes as if 
dispersion were possible. This happy result is not, indeed, attained 
in the majority of cases, but inaction will never satisfy the patient 
and the success of remedies in a few instances will amply compen- 
sate for their employment in all; since a suppurating bubo is a 
source of considerable pain and great annoyance, generally neces- 
sitates confinement in bed for several days at least, exposes the 
patient to detection, and may leave an indelible cicatrix. The idea 
formerly entertained that danger would result from the "repulse of 
matter" if buboes were dispersed, is now known to be without 
foundation. 

The means employed to effect resolution are an antiphlogistic 
regimen (rest and -low diet), cathartics, local depletion, counter- 
irritants, and compression. 

General Treatment. — General remedies are not always required. 
"When the inflammation is subacute, local applications may be relied 
upon from the first. 

Eest is of course of the first importance ; and the more absolute, 
the better. It would appear that common sense would suggest this 
to every one with a commencing bubo, but if the surgeon rely upon 
the patient's intelligence alone, he will in most cases be disappointed, 
and will find that the swelling has been aggravated by a long walk, 
or by what is equally detrimental, the standing posture. Rest upon 
the back should in all cases be secured, if possible. An active 
cathartic at the outset will rarely be amiss, and an evacuation from 
the bowels should be obtained daily. If the patient be of full 
habit, his diet should be low; but when the system is already 
depressed or cachectic, strict abstinence will favor suppuration, and 
should be avoided. 

Similar rules should govern the use of local depletion, the benefit 
from which, however, is so uncertain as scarcely to compensate for 
its inconvenience ; yet when the patient is plethoric, and the local 
symptoms acute, from six to a dozen leeches may be applied near 



680 BUBOES. 

(not upon) the tumor, and the bleeding be promoted by immersion 
in a hot bath ; but leeches should never be used when an abscess 
has formed and is upon the point of opening, lest their bites be 
inoculated and transformed- into chancroids. The administration of 
a solution of Epsom salts and tartar emetic may often be advan- 
tageously substituted for abstraction of blood in any manner. 

No benefit can at this period be expected from specific remedies. 
Mercury is uncalled for, since the inflammation is not at all dependent 
upon the action of the syphilitic virus. I have frequently employed 
iodide of potassium, but never with perceptible effect unless in 
strumous subjects. Prof. Hebra recommends the administration of 
Zittman's decoction in the indolent or scrofulous bubo. 

The large number of local applications recommended in the early 
treatment of buboes proves how little dependence can be placed 
upon any of them. Nearly all of them act as counter-irritants, or 
aim to produce absorption and resolution by compression. To this 
remark ice is an exception, which if applied to a bubo at its very 
commencement before acute inflammation is set up will sometimes 
discuss it. 

Counter-irritants. — One of the best counter-irritants is the strong 
tincture of iodine. I do not attribute its beneficial action to any 
special power of inducing absorption, but rather to the inflammation 
of the skin which it excites. The same may be said of the following 
ointment, which I am also in the habit of using : — 

R. Potassii iodidi ^j. 

Iodinii gr. v. 

Unguenti hydrargyri ijj. 
M. 

Either of these preparations may be applied twice a day until as 
much inflammation is induced as the patient can well bear, when the 
application must be less frequent. 

A strong solution or the solid crayon of nitrate of silver is 
another excellent counter-irritant highly recommended by Mr. Henry 
Thompson, 1 whose paper on the subject first induced me to try it. 
The strength of the solution is three drachms of the nitrate of silver 
to the ounce of water with the addition of twenty minims of strong 
nitric acid. This should be freely applied to the whole surface 
of the tumor and be repeated as soon as the eschar comes away; 
or the solid nitrate of silver may be employed by first moistening 
the part with water and then rubbing the crayon for a few minutes 
upon it. 

1 London Lancet, Am. ed., June, 1855, p. 536. 



METHODS OF OPENING BUBOES. 38 L 

A blister may be employed for the same purpose and the vesicated 
surface be dressed with various irritant or resolvent ointments. 
When the acute symptoms have somewhat subsided, or at the outset 
of virulent buboes, Eicord recommends that the blister should be 
dressed twice a day with half a drachm of strong mercurial ointment, 
and be covered with a rye-meal poultice which should be chaDged 
three or four times in the twenty -four hours. A caustic solution of 
the bichloride of mercury, proposed by MM. Malapert and Eeynaud 
for the treatment of buboes after suppuration has taken place, has 
also been employed by some surgeons for the purpose of inducing 
resolution. 

A few years since a favorite mode of treatment of subacute 
buboes in the French hospitals was by means of "cauterisation 
ponctuee," or the rapid application of a pointed iron heated to a 
white heat to numerous points over the tumor. This method wag 
tried at my suggestion at Bellevue Hospital in this city with very 
satisfactory results. The dread rather than the pain of the applica- 
tion, which does not exceed that produced by many caustics, inter- 
feres with its adoption in private practice. 

Compression. — Compression is another means employed to induce 
resolution of buboes, and is said to have been suggested by the 
observation that these tumors do not occur wherever a truss is worn. 
The most ready method of applying pressure is by means of com- 
pressed sponge and a spica bandage, and the application of hot water 
to cause the sponge to swell. An Interne of the Hopital du Midi 
has invented a truss or pad for the same purpose, consisting of a 
rounded piece of wood covered with leather, and provided with 
straps to pass round the waist and thigh. This may be obtained at 
most instrument makers, and is very convenient and serviceable. 
It is generally called "Bicord's pad for buboes." Reynaud 1 com- 
bines heat and pressure by heating the half of a common brick, the 
edges of which have been chipped off, wrapping it in a napkin, laying 
it upon the bubo, and changing it at the end of three or four hours, 
by which time it becomes cool. 

The application of collodion, which, by its power of contraction, 
exerts pressure upon the tumor, has been recommended by Dr. J. H. 
Clairborne and others. 

Methods of Opening Buboes. — So soon as matter can be detected, 
and it is evident that resolution is impossible, the abscess should at 
once be opened. Delay will allow the pus to collect and undermine 

1 Traits des Maladies Veneriennes, p. 76. 



882 BUBOES. 

the skin, which, becoming thin and deprived of its vascular supply, 
will be destroyed to a greater or less extent, thereby increasing the 
difficulty of cicatrization and adding to the dimensions of the un- 
sightly scar. 

The knife is in most cases preferable to caustic for this purpose. 
The extent and number of incisions to be made have been the sub- 
ject of much discussion, and have called forth a great diversity of 
opinion. The chief question has been between a single free open- 
ing and a number of small punctures. The object proposed in these 
two methods is different. In the first, it is intended to transform 
the abscess into an open wound which will heal by granulation from 
the bottom ; in the second, which is the less painful method, the 
design is to simply evacuate the contents of the swelling and secure 
adhesion of its "walls, and thus expedite the cure and avoid the forma- 
tion of a cicatrix. These latter results are indeed highly desirable 
provided they can be attained, but my own experience has led me 
in most cases to give a decided preference to the former course ; 
since in numerous trials with multiple punctures, the matter, not 
finding free exit, has burrowed in various directions, and it has 
become necessary to resort to a free incision before cicatrization 
would take place. 

My manner of proceeding is as follows. The hair should be 
thoroughly shaved from the surrounding parts to facilitate the after- 
dressing and promote cleanliness. If the patient be nervous, I 
administer ether so as thoroughly to explore the abscess without 
interruption. Entering the point of the knife at the most dependent 
part of the tumor, I carry the incision upwards parallel with the 
median line of the body to the full extent of the cavity. An incision 
in this direction is preferable to one in the course of the inguinal 
fold, since its edges are separated while those of the latter are ap- 
proximated, by flexure of the thigh. Exposure to the air generally 
arrests the hemorrhage in a few moments, when I carefully examine 
the walls of the cavity for sinuses, and if any are found extending 
more than half an inch beneath the surface, I slit them up with a 
probe-pointed bistoury. Glands nearly isolated by the suppuration 
of the surrounding cellular tissue, and attached only by a small base 
or pedicle, are often found projecting into the cavity ; and having 
been taught by experience that the wound does not commonly heal 
until these are cast off by a slow process of ulceration, I remove 
them with scissors or tear them out with the ringers when this can 
be done without much violence. Or, again when they have been 
large and sessile, I have passed a double ligature through their base, 



METHODS OF OPENING BUBOES. 383 

and tying the two halves in opposite directions, have allowed the 
included portion to slough off. If left, their dark sloughy surface 
is perceptible for a long time, and they doubtless prolong the process 
of cicatrization. Any fistulous tracks which may exist at the time 
of opening the bubo, or which may subsequently form, should be 
fully laid open throughout their whole extent. 

The hemorrhage from this operation is seldom so severe that it 
may not be arrested by exposure to the air, by ice, or pressure ; but 
should it be profuse, or continued even in a small quantity, the 
bleeding vessel must be secured. I once saw a patient in whom a 
bubo had been opened, and who was completely blanched by a 
slight oozing of blood which had been allowed to go on for a num- 
ber of days, beneath the coagulum which formed upon the surface. 

Scraped lint, either dry or moistened in a mixture of laudanum 
and water, is now introduced into every recess of the cavity, paying 
particular attention to any short sinuses which it was not thought 
necessary to lay open with the knife, and a poultice or water-dressing 
applied. The pain and difficulty of motion which probably dimin- 
ished on the first formation of matter, again increase for a few days, 
but are not severe if the patient keep quiet on his back. The first 
dressing, which becomes glued to the wound by coagulated blood, 
is loosened about the third day by the free secretion of matter, and 
should be removed, having first applied a hot poultice for a few 
hours. The subsequent dressings may consist of lint smeared with 
simple or medicated cerate, or moistened with any of the lotions 
recommended in the treatment of chancroids (as nitric acid and 
water, aromatic wine, Labarraque's solution, or the potassio-tartrate 
of iron), and will require to be changed twice a day. The cavity 
should from time to time be examined, and any burrowing sinuses 
that may be found be slit up with the knife ; those of small extent, 
however, may be made to close by filling them carefully with lint at 
each dressing. The rapidity with which the wound contracts by 
granulations from the bottom and the approximation of its sides, is 
often astonishing, and but from two to four weeks are generally 
required for complete cicatrization to take place, during which time 
it is desirable that the patient should be confined to his room. 

But though I cannot subscribe to the high encomiums bestowed 
upon multiple incisions, and think that they are inapplicable to the 
treatment of most buboes, yet I believe that they may be used with 
advantage in a few cases in which the abscess is superficial, and the 
sVin over a considerable surface so thin and of such low vitality 
4 »at a free incision would probably result in its total disorganization. 



384 BUBOES. 

In such instances, a number of punctures with a bistoury or a 
grooved needle may be made around the margin of the tumor (as 
recommended by Vidal) rather than towards its centre, and the 
contents be allowed to drain away. Continued pressure should be 
applied after the lapse of twenty-four hours by means of compresses 
and a spica bandage, in order to prevent any farther collection of 
matter and secure adhesion of the walls. Even when these objects 
are not attained, the abscess will have time to contract, and a subse- 
quent free incision may, if necessary, be made with less destruction 
of the integument. 

Langston Parker's favorite treatment is as follows: "When a 
bubo is ready to be opened, we should not suffer the skin to become 
too thin, but make several very small punctures over its thinnest 
part with a grooved needle, perhaps six, eight, or ten ; through these 
the matter will ooze out till the cavity of the abscess is empty. 
Through one of the punctures the point of a very small glass syringe 
may be introduced, and a very weak solution of the sulphate of zinc 
injected, in the proportion of two or three grains \o the half-pint of 
water. When the abscess is quite empty, place over it a large 
compress of lint, and use moderately tight pressure by means of a 
roller. In many instances, if we can keep the patient quiet for 
twenty-four hours, we get either partial or total adhesion of the 
sides of the bubo, and a speedy cure will be the resul-t ; in other 
instances this may not be the case, but by the daily use of the 
injection through one of the punctures, which should be kept open 
for that purpose, we succeed in a few days, in almost every case, in 
effecting a cure." l I wish that I were able to confirm the above 
praise of this method to its full extent. 

Eoux (de Toulon) and Marchal (de Calvi) have proposed to inject 
buboes immediately after opening them with a mixture of one part 
of tincture of iodine to three or four of water. Langston Parker 
sometimes employs a solution of iodine and iodide of potassium, aa 
follows : — 

R. Iodinii gr. iv. 

Potassii iodidi gr. viij. 

Aquae ^viij. 
M. 

A filiform seton recommended by Bonnafont, and also by Mr. 
Parker, was reported against by a committee of the Soc. de Mdd. de 
Paris, in 1859. 

1 The Modern Treatment of Syphilitic Diseases, Phil., 1854, p. 148. 



TREATMENT OF DIFFICULT CASES. 3S5 

The use of caustics in opening buboes has been advised by several 
authors, but finds few advocates at the present day. 

The method of MM. Malapert 1 and Keynaud, 2 which acquired 
some notoriety for a time, and was extensively used at the Emigrants' 
Hospital, Deer Island, Boston, when I was a student of medicine, 
consists in the application of a blister over the tumor, and of a 
pledget of lint soaked in a solution of corrosive sublimate (gr. xv 
to 3j of water) to the vesicated surface previously freed from all 
secretion of serum. The caustic is allowed to remain for two hours, 
or until a superficial eschar is formed, when a large poultice is 
applied. The authors of this method claim that as the eschar is 
detached, the contents of the abscess ooze out through minute open- 
ings in the integument, the whole substance of which is not destroyed, 
and that the walls of the cavity are so stimulated and modified by 
the caustic that they rapidly contract and adhere. As stated upon a 
previous page, this method, although designed by its authors solely 
for the treatment of buboes after suppuration has taken place, has 
been applied by others for the purpose of effecting resolution. The 
excessive pain attending the application is not counterbalanced by 
any advantage over milder methods. 

Treatment of Difficult Cases. — Unfortunately all buboes do not heal 
so readily as the reader might infer from the preceding remarks, 
which are intended to apply to the more favorable cases constituting 
doubtless the majority. Persistent buboes may be divided into two 
classes : 1st. Virulent buboes which take on phagedenic action and 
pursue a course similar to phagedenic chancroids upon the genitals, 
and which may extend to a considerable distance beyond the inguinal 
region, giving rise to large open sores ; and, 2d. Those which are 
maintained, not by the presence of the chancroidal virus as in the 
former class, but by some morbid diathesis or general cachexia, and 
which are generally limited to the groin, where they burrow in 
various directions beneath the surface, without causing extensive 
ulceration of the integument. 

The treatment of buboes belonging to the first class is the same 
as that of the phagedenic chancroid, for which I would refer the 
reader to a preceding chapter. At present I would simply recall to 
mind the danger of the internal use of mercury or its topical appli- 
cation to the spre in the form of ointment, etc., and to the benefit to 
be derived from nourishing diet, fresh air, tonics (especially the 
potassio-tartrate of iron), and opium internally; and locally from 

i Arch. G^n de Med., March, 1832. 
2 Traite* des Maladies Vene'riennes, p. 70. 
25 



386 BUBOES. 

cleanliness, deep cauterization with nitric acid, Vienna paste, or the 
actual cautery, and suitable lotions and dressings. 

Cases belonging to the second class are met with in persons in 
whom the glandular swelling has been allowed to go on unchecked, 
or whose general condition or neglect to comply with the surgeon's 
directions has rendered treatment of no avail ; and they are especially 
frequent in patients of a strumous habit and in those who have been 
debilitated by intemperance, an irregular course of life, antecedent 
diseases, want, or other causes. 

To this class belong most of the so-called " constitutional buboes," 
occurring in persons who are really laboring under syphilis, but 
which are not, strictly speaking, to be regarded as syphilitic symp- 
toms, since syphilis has merely acted like any other depressing 
influence in predisposing to a low form of inflammation and suppu- 
ration. Instances of this kind are frequent ; advice is sought by a 
patient who evidently has syphilis and who has perhaps arrived at 
the tertiary stage ; his general condition is very low ; he complains 
of nocturnal pains, and exhibits a patch of rupia upon the arm, and 
also a large, oval, firm and projecting tumor in one or both groins ; 
its longer diameter corresponding to the inguinal fold, its surface 
studded here and there with fistulous openings, and presenting at 
some distance soft or fluctuating points, pressure upon which forces 
from the mouths of the connecting sinuses a small quantity of thin, 
sero-purulent fluid — symptoms, in short, of the indolent bubo, above 
described ; the surgeon is at first disposed to look upon the case as 
one of the exceptions to the rule that syphilis does not follow an 
open bubo, but he finds on inquiry that the glandular tumor is of a 
much later date than the constitutional disease ; that it followed a 
chancroid or excessive sexual indulgence, or arose without any 
apparent exciting cause, and that it has clearly no direct connection 
with the original chancre. Has the reader never observed a very 
similar condition in the axillae of poor, half- starved, and over- 
worked washerwomen, in whom there could be no suspicion of 
svohilis ? 

Whatever the depressing cause may be, it should if possible be 
removed and the system be brought into a better condition before 
benefit can be expected from local treatment. Favorable hygienic 
influences, a simple but nourishing diet, and tonics'are required in 
all cases ; and, in strumous subjects, iodine, the iodides of potassium 
and iron, and cod-liver oil. Eecollect that the presence of a bubo 
by no means proves that the patient has syphilis, the existence of 
which should not be admitted until after the most careful and 



TREATMENT OF DIFFICULT CASES. 387 

thorough examination. Should this fact be clearly established, 
specific remedies will sooner or later be required. If the consti- 
tutional disease be in the tertiary stage, iodide of potassium may be 
freely given and will prove the best tonic that can be found ; but 
mercury should be administered with great caution and combined 
with quinine or iron, or be altogether deferred until the general 
health has been improved by the means above indicated. No course 
of treatment which adds to the existing depression of the system 
will benefit the local affection. 

As the patient's health improves, the bubo generally assumes a 
more favorable aspect, and if it does not entirely heal will yield to 
remedies which were before powerless. When the sinuses are not 
too deep or extensive, they should be slit up and dressed from the 
bottom with lint, or their walls be pencilled with a crayon of nitrate 
of silver. When this course is inadmissible, I believe that the best 
results are obtained from injecting them with diluted tincture of 
iodine every few days, and applying pressure over the tumor by 
means of compressed sponge and a roller, or with Eicord's pad. 
Under one or the other of these methods they will rarely fail to 
cicatrize. In desperate cases, Eicord resorts to the destruction of 
the diseased ganglia by Vienna paste, in the following manner: 
" This caustic is applied over an extent of two-thirds of the tumor, 
so as to destroy the cutaneous surface, then on the fall of the eschar, 
which is hastened by basilicon ointment and other digestives the 
ganglia are attacked layer by layer ; increasing our caution as we 
proceed in depth, and stopping within accessible limits, or when we 
approach the neighborhood of vital parts. This method is generailv 
very rapid, and the deep ganglia undergo resolution as the super- 
ficial ones are destroyed." ' 

1 Notes to Hunter, 2d ed\, p. 390. 



383 LYMPHANGITIS. 



CHAPTER VI. 

LYMPHANGITIS. 

Having described the inflammation of the ganglia which consti- 
tutes a bubo, it will be necessary to devote but a few words to the 
consideration of lymphangitis ; since the phenomena are almost 
identical in the two cases ; the latter being in fact a bubo seated 
in the course of a lymphatic vessel instead of in the terminal 
ganglion. 

As a general rule, morbid products which undergo absorption do 
not manifest their presence in the lymphatics themselves, probably 
in consequence of the rapidity of their passage ; and the changes 
which take place in the ganglia where their progress is impeded, 
are the only indication that this system of vessels is affected. In 
conformity with this law, the lymphatics which convey the pus 
from a chancroid in the direction of the ganglion generally escape, 
but in some instances inoculation takes place at one or more points 
m the course of the vessel and virulent lymphangitis is set up. 

Virulent lymphangitis most frequently accompanies a chancroid 
of the prepuce. A hard, uneven chord is observed running along 
the dorsum of the penis towards the mons veneris in which it is 
usually lost. This chord is made up in part of the thickened and 
distended walls of tire lymphatic vessel, but in part also of the 
infiltrated cellular tissue in its neighborhood. The dorsal vein and 
artery are usually included in the inflammatory engorgement and 
cannot be isolated from the vessel. Considerable heat and pain are 
experienced, and the course of the inflamed vessel is marked by a 
red line upon the surface. • As we shall see hereafter, these symp- 
toms of acute inflammation are sufficient to distinguish lymphangitis 
from the induration of the lymphatics which often accompanies a 
chancre. 

Virulent lymphangitis, like a virulent bubo, necessarily termi-. 
nates in suppuration ; abscesses form at one or more points in the 
course of the vessel, and, when opened, present the usual symptoms 



LYMPHANGITIS. 389 

of chancroids, and require the same treatment. A gland in the 
groin may, or may not be similarly affected at the same time. 

The symptoms of simple lymphangitis which may also attend the 
chancroid as well as a gonorrhoea, do not vary from the above, 
except that resolution is possible, and if suppuration take place the 
pus is not inoculable. 



PART III. 
SYPHILIS. 



CHAPTER I. 

INTRODUCTORY KEMARKS. 

Syphilis is one of the class of diseases called "infectious," the 
characteristics of which are the following : — 

1. The presence of a morbid poison or virus, which transmits the 
disease from one individual to another. 

2. The immunity which one attack generally confers against a 
second. 

3. A " period of incubation," during which the virus is latent and 
gives no external manifestation of its presence in the system. 

4. A degree of order and regularity in the evolution of the 
symptoms. 

Syphilitic Yirus. — The existence of a syphilitic virus has 
sometimes been called in question, 1 but at the present day is estab- 
lished beyond a doubt. The daily experience of every surgeon 
demonstrates that in syphilis there exists a contagious element, by 
means of which the disease is communicated;* and though this 
morbid poison has never been detected by the senses, the micro- 
scope, or chemical analysis, its presence is fully proved by its 
effects. Yarious theories have been offered to explain its nature, 
but they have all been either fanciful or untenable, and their authors 
have invariably confounded the syphilitic with the chancroidal virus. 

1 Chiefly by the following authors : Bbu, Me"thode Nouvelle de traiter les Maladies 
Veneriennes par les gateaux toniques mercuriels, t. i., chap. 3, p. 45. Paris', 1789. 
Caron, Nouvelle Doctrine des Maladies Veneriennes. Paris, 1811, p. 33. Richond 
des Brus, De la. Non-existence du Virus Venerien. Paris, 1826, t. i., p. 76. Jour- 
dan, Traite - complet des Maladies Veneriennes, t. i., p. 388. 

(391) 



392 INTRODUCTORY REMARKS. 

Thus the essential element of this disease has always remained con- 
cealed, and probably always will, until our knowledge in general of 
the principle of life and the nature of disease is very much greater 
than now. 

The severity of the symptoms produced by syphilis on its first 
appearance in the latter part of the fifteenth century, compared with 
its greater benignity at tne present day, affords some ground for 
# believing that its virus is slowly but gradually losing in intensity 
in the same manner as the vaccine virus becomes weaker after many 
successive removes from the cow. This fact was noticed by Astruc 1 
in the middle of the last century, who says : " "Whatever might for- 
merly be the power and efficacy of the venereal disease when it was 
new and in vigor, while the undivided poison violently effervesced, 
there is nothing like it, I imagine, to be feared from it now, as it is 
weakened, becomes old, and its force almost quite spent." Another 
explanation advanced by some writers is, that the syphilitic virus 
retains its power, but that a preservative influence is transmitted to 
posterity by those who have the disease, which, like some vegetables, 
gradually exhausts the soil from which it springs of the materials 
necessary to its support. Admitting the fact, the first mentioned 
theory is probably the correct one. 

Syphilis commonly occurs but once in the same person. — 
It is true of all diseases which are both contagious and constitu- 
tional, that a person who has once had them is indisposed to con- 
tract them again. Smallpox, scarlet fever, measles, the hooping 
cough, and vaccine disease, all follow this law ; and in the rare ex- 
ceptions which sometimes occur, the symptoms are generally so 
modified as still to evince the protecting influence of the first attack. 
The applicability of this law to syphilis was first announced by 
Bicord in 1839, and, in spite of frequent denials, may now be 
regarded as unquestionable. The immunity conferred by an attack 
of syphilis is as great as that resulting from an attack of any of the 
other infectious diseases just mentioned. 

Without due care, however, it is an easy matter to be deceived on 
this point. After syphilitic infection, but few persons escape with 
only one outbreak of general symptoms; however thorough their 
treatment may have been, one or more relapses usually occur, ana 
if one of these has been preceded by a newly caught venereal ulcer 
the secondary symptoms which follow are frequently ascribed to its 

1 English translation of Astruc, London, 1754, p. 102. 



UNICITY OF SYPHILIS. 393 

influence, especially if the ulcer happened to be situated upon the 
remaining induration of the first, and thus similated a chancre. 
Fortunately, we are able in most instances to recognize a recent 
attack of syphilis by the following signs, and in their absence to 
ascribe the symptoms to an old infection : — 

1. By the induration of the preceding chancre and neighboring 
lymphatic ganglia. 

2. By the time elapsing between the appearance of the suspicious 
ulcer and that of the general symptoms; the interval, in the absence 
of treatment, and when the latter are dependent upon the same 
infection as the former, being very uniformly about six weeks, and 
rarely exceeding three months. 

3. By the character of the symptoms, whether belonging to an 
early or late stage of syphilis. 

4. In some cases, by the influence of treatment ; the early symp- 
toms of general syphilis yielding most readily to mercury ; the later 
to iodide of potassium. 

But are there no exceptions to the law of the " unicity of syphilis," 
such as undoubtedly exist in respect to other infectious diseases ? 
Numerous instances are recorded in which small-pox, scarlet fever, 
the measles, and hooping cough have occurred twice in the same 
person. A single vaccination does not always protect one through 
life from variola. A second inoculation with the vaccine virus per- 
formed in adult life will often succeed nearly if not quite as well as 
the first vaccination performed in childhood. In the case of a second 
infection from any of the diseases mentioned, the severity of the 
attack will, as a general but not invariable rule, be in inverse ratio 
to the length of time which has elapsed since the previous infection. 
In other words, the protecting influence of the virus appears to 
gradually diminish and finally disappear. One attack confers 
complete immunity for a time ; then comes a period in which inoc- 
ulation (as of the variolous or vaccine poisons) will produce a 
local effect without general reaction ; and finally a third period in 
which constitutional manifestations of greater or less intensity are 
possible. 

As early as 1845, Ricord himself expressed the belief that similar 
exceptions to the law of the unicity of syphilis would also be found 
to exist; he trusted it was so, since it would prove that the effect of 
syphilis was not necessarily life-long ; at the same time he confessed 
he had never as yet met with an unquestionable instance. 

Within the last few years, attention has been directed anew to 
this subject. Scattered cases of repeated syphilitic infection in the 



39-i INTRODUCTORY REMARKS. 

same person have been reported by various observers, and Eicord 
himself has met with two which he regards as conclusive. By far 
the most valuable contribution, however, to our knowledge of 
syphilitic reinfection has recently appeared from the pen of Diday, 1 
who has been fortunate enough to meet with over twenty cases, and 
who is the only syphilographer who has carefully studied the phe- 
nomena resulting from a second inoculation. The conclusions at 
which he has arrived and which are entitled to the highest consider- 
ation are the following : 

1. As a general rule, the syphilitic, like other kinds of virus, does 
not exercise the same action twice in succession upon the same 
individual. 

2. When applied (under such conditions as to permit absorption) 
to a syphilitic subject, this virus produces no effect; applied to a 
subject who has had, but who no longer has syphilis, it produces a 
modified form of syphilis. 

3. The more feeble the first attack, and the longer the time that 
has since elapsed, the more energetic will be the action of the virus 
and the more severe will be the second attack of syphilis ; and vice 
versa. 

4. Experience shows that the only persons upon whom a second 
introduction of the syphilitic virus produces a pathological effect 
are those who are cured of their first attack, or who at least have no 
other symptoms than those which cannot be transmitted either b} r 
generation or by contact (tertiary symptoms). 

5. The effects of the second introduction of the virus, under the 
conditions just mentioned, have presented in twenty-five cases which 
have been observed, the following varieties : — 

A. In fourteen, there has been an ulcer presenting all the charac- 
teristics of an indurated chancre, except concomitant induration of the 
ganglia, and this ulcer has not been followed by general symptoms. 
Thus the absence of glandular induration may enable the surgeon 
to recognize in advance those indurated chancres which will not be 
followed by general symptoms. 

B. In nine cases, there was an indurated chancre followed by 
general symptoms, which were less intense than those of the first 
attack. 

C. In two cases, there was an indurated chancre followed by 
general symptoms of greater intensity than in the first attack. 

1 De la Reinfection Syphilitique, de ses Degrgs et de ses Modes Divers, Arch. Ge*n. 
de Me"d., Juillet et Aout, 1863. 



EVOLUTION OF SYPHILITIC SYMPTOMS. 395 

6. If we compare the intervals of time elapsing between the two 
attacks in these different series of cases, we find that the shorter the 
interval the more feeble was the effect of the second infection ; the 
interval being at a minimum when the second attack produced only 
a chancre, and at a maximum when the general symptoms of the 
second attack were more intense than those of the first. 

No less than twenty of the cases above referred to were observed 
by Diday in his private practice within a period of six years, and 
he therefore infers that instances of syphilitic reinoculation are more 
frequent than has generally been admitted, although they are rare 
when compared with the whole number of cases of syphilis that 
occur. This surgeon draws the following conclusions from a con- 
sideration of this subject : — 

The reinfection of a man who has had syphilis proves that he was 
cured of it at the time of the second infection. 

The possibility of reinfection proves that syphilis can be radically 
cured — a fact denied by many authors, who admit only a cure of 
syphilitic manifestations, and who maintain that the constitutional 
poisoning (or diathesis, as they erroneously call syphilitic intoxication) 
is perpetual. 

The average time necessary for a radical cure may be deduced 
from the cases above referred to, and which give a minimum of 
twenty -two months. 

Finally, in any case of reinfection from syphilis, the surgeon 
should always wait for general symptoms to appear before giving 
mercury, since in the majority of cases the effect is limited to the 
production of a chancre, and specific treatment is not required. 

• Syphilis possesses a pekiod of incubation. — By a period of 
incubation we understand the lapse of time following the introduc- 
tion of a morbid poison into the system, and preceding the earliest 
manifestation of its presence. Thus a person is exposed to small- 
pox, the measles or scarlatina, and when contagion takes place, breaks 
out with the symptoms of the disease only after an interval, which, 
with slight variation, is constant in each of the affections mentioned, 
and during which he enjoys his usual state of health. That syphilis 
possesses such a period of incubation will be shown when treating 
of its initial lesion, or the chancre so-called. Again, in a subsequent 
chapter, the reader will find that the general manifestations ' of 
syphilis are also preceded by a period of quiescence of the vims, 
following the appearance of the chancre. 



396 introductory remarks. 

The order of evolution of syphilitic symptoms and the 
classification founded thereon. — The classification of syphilitic 
manifestations in common nse is fonnded chiefly npon the order ot 
their evolution, and embraces "primary," "secondary," and "ter- 
tiary symptoms." Primary symptoms should include the initial 
lesion which appears at the point where the virus enters the economy, 
and the induration of the neighboring lymphatic ganglia. Next 
follows, after a period of incubation, another set of symptoms, called 
" general," because they are developed at points distant from the seat 
of the initial lesion, to which they stand in no necessary anatomical 
relation. 

Eicord's classification of general symptoms into secondary and 
tertiary, which is generally adopted at the present day, is founded 
upon Hunter's division of the tissues affected by syphilis into " parts 
first in order, and parts second in order." Both systems are based 
upon the conformity of nature to laws which are more or less fixed 
as well in disease as in health, and upon the anatomical structure 
of the parts affected. An important distinction, also, which Eicord 
claims to exist between the two divisions in this classification, is a 
difference in the effect of remedies ; secondary symptoms being more 
susceptible to mercury, and tertiary to iodine and its compounds. 

Eicord's classification may best be given in his own words : " Sec- 
ondary symptoms are the consequence of the absorption of the virus, 
and are transmissible by hereditary descent, without being inocula- 
ble. Tertiary symptoms' are not only not inoculable, but cannot be 
transmitted by hereditary descent under their pecular type, although 
in consequence of a kind of degeneration or modification of the 
syphilitic virus, they are probably one of the most fruitful sources 
of scrofula. 

" Secondary symptoms rarely occur before the third week follow- 
ing the appearance of primary symptoms, and more rarely still after 
the sixth month ; whilst tertiary symptoms scarcely ever appear be- 
fore the sixth month, and may not until after several years. 

"To secondary symptoms are referred certain affections of the 
skin (syphilitic eruptions) and of some parts of the mucous mem- 
branes (mucous patches, condylomata and superficial ulcerations) 
and their dependencies (alopecia and onyxis) ; also some peculiar 
pathological affections of the eyes (iritis), lymphatic ganglia (en- 
gorgement of the glands in various parts of the body, especially the 
neck), etc. Tertiary symptoms consist of certain changes which 
take place in the subcutaneous or submucous cellular tissue (gummy 



CLASSIFICATION OF GENERAL SYMPTOMS. SO' 7 

tumors), in the testicles (orchitis), in the fibrous and osseous tissues 
(periostitis, ostitis, caries, etc.), and in the deeper organs. 

" Proper treatment of the primary symptom may prevent the de- 
velopment of secondary symptoms. Very often this treatment cures 
the primary and arrests only the secondary symptoms ; in this way 
may be explained, for example, the late appearance of diseases of the 
periosteum and bones, without the secondary link, in persons who 
have taken mercury. When once the primary ulcer is healed, it 
cannot be reproduced except by a new contagion ; while secondary 
and tertiary symptoms may appear repeatedly, and at various inter- 
vals, within periods which cannot be limited. An apparent inver- 
sion in the succession of secondary and tertiary symptoms is observed 
only in persons who have undergone treatment. After the appear- 
ance of constitutional symptoms, the syphilitic diathesis may cease 
spontaneously or in consequence of appropriate treatment, and yet 
the symptoms persist under the influence of purely local causes, as 
is observed especially in many cases of diseased bones." 1 

In another place Eicord says of tertiary symptoms : " They not 
only differ from primary and secondary symptoms in affecting the 
deeper tissues, but also in the fact that in them syphilis loses, in 
part, its peculiar type. Though the skin is often affected at this 
period with the most severe tubercular eruptions, yet the subcu- 
taneous and submucous cellular tissues, and the fibrous and osseous ■ 
systems are far more frequently involved. But, in addition to 
these parts, where the tardy effects of constitutional syphilis are so 
common and clearly admitted by all good observers, we may well 
inquire whether there be any privileged tissues of the body which 
are invariably exempt from its effects. We would inquire, also, if 
syphilitic infection, though it may not produce all the evils with 
which it is reproached, be not in a multitude of cases the cause of 
the evolution, or 'putting into action' — to use an expression of 
Hunter's — of diseases which have previously existed in a latent 
state, and of which it is thus only the exciting cause. Observation 
replies in the affirmative to these questions, and also teaches us that 
tertiary symptoms may continue under the influence of the virulent 
cause, or persist as local effects after this cause has been destroyed 
01 neutralized by treatment ; it shows, in a multitude of cases, that 
the syphilitic virus, after having been the cause of other diseases, 
may cease to exist or persist as a complication ; and these are cir- 
cumstances which, though real, are unfortunately not always easily 

appreciated. 

1 Notes to Hunter, p. 396. 



398 INTRODUCTORY REMARKS. 

" Tertiary symptoms rarely occur before the sixth month following 
the appearance of the primary ulcer, and the latter seldom remains 
at the time of their development ; but they are frequently attended 
by some secondary symptom. They never furnish inoculable secre- 
tions, nor transmit characteristic constitutional syphilis from parent 
to child ; their only hereditary influence being the frequent trans- 
mission of a taint as injurious and almost as fearful, viz., a scrofulous 
diathesis." 

'Ricord's classification may, I think, be resolved into two parts. 
The first is the chronological system, which, originating with Fernel 
and Hunter, has been freed from many errors by Ricord, and greatly 
perfected by this surgeon's keen powers of observation, and which 
is both natural and eminently practical. The second part consists 
of various additions relative to the inoculability of the different 
orders of symptoms, their transmission by hereditary descent, and 
the effect of treatment ; some of which are open to criticism. I shall 
speak of each in turn. 

The general symptoms of syphilis are not drawn at hap-hazard, 
but make their appearance with a great degree of order and regu- 
larity. This fact is most apparent in those lesions which follow 
immediately upon the period of incubation, and which Vary but 
little in different subjects. Allow any patient with a chancre to 
go without treatment, and it may be predicted with almost absolute 
certainty, that within three months he or she will be attacked by 
the following category of symptoms with but little variation, viz., 
general lassitude, accompanied by headache and fleeting pains in 
various parts of the ' body ; alopecia ; an eruption of blotches or 
papulae upon the skin ; pustules upon the hairy scalp ; engorge- 
ment of the post-cervical glands ; and whitish patches, which may 
become ulcerated, upon the mucous membrane of the mouth, anus, 
or vulva. 

Subsequent to the first outbreak of general syphilis, the same 
uniformity does not prevail; and certain symptoms are absent in 
one case and present in another, or they appear to be modified by 
the constitution of the patient, the hygienic conditions in which he 
is placed, his habits, and especially by treatment. But if we take 
a number of cases, some of which supply what is wanting in 
others, we find that we can, as it were, make up a complete series, 
in which the symptoms progress by a regular gradation, and may 
be divided into two classes, distinguishable by the time of their 
appearance, their character, and their seat. Those of the first class 
follow immediately upon the earliest general symptoms before men- 



CLASSIFICATION OF GENERAL SYMPTOMS. 399 

tioned, with which they are evidently identical in character. Those 
of the second class never occur until after a certain interval which 
experience enables us to determine with great precision. Agaifc, the 
order of the two classes is never reversed, For instance, a patient 
who has been suffering with symptoms belonging to the second, as 
deep tubercles of the cellular tissue or caries of the bones, is never 
known to exhibit the premonitory fever, exanthematous eruption, 
and other early symptoms of the first. The disease progresses with 
greater rapidity in some cases than in others, yet owing to the 
general uniformity referred to, simple inspection of a patient will 
enable any one familiar with its natural course to arrive at an 
approximate conclusion as to the length of time that has elapsed 
since contagion, and also as to the character of the preceding symp- 
toms, unless these have been altogether suppressed by treatment. 

Apparent exceptions to the regular succession of the general 
symptoms of syphilis are met with, and may readily deceive an 
inexperienced observer. One of the most frequent of these is due 
to treatment. It often happens that a patient had a chancre many 
years ago, and perhaps early secondary symptoms, for one or both 
of which he took mercurials ; a long period has since passed without 
further general manifestations ; but his system has continued under 
the influence of syphilis, which finally becomes active again and 
gives rise to tertiary lesions. Evidently the exemption from late 
secondary symptoms may be ascribed to mercury. 

Again, the date of the first appearance of any lesion determines 
its position in the syphilitic scale ; while its persistency may be due 
to many causes, too numerous to mention. It is a very common 
occurrence for a chancre to remain until secondary symptoms break 
out ; but we do not therefore conclude that both belong to the same 
order. In the same way, secondary are often present long after 
tertiary manifestations have supervened. In Eicord's admirable 
remarks already quoted, allusion has been made to the fact which I 
have often had occasion to verify, that syphilis may give rise to 
symptoms, which are continued by various causes and especially 
by a strumous diathesis, long after the exciting cause has been 
subdued. Moreover, many syphilitic lesions, and particularly erup- 
tions upon the skin and mucous membranes, may, either with or 
without treatment, disappear, and again .return within a limited 
period with the same characters as at first. This tendency, however, 
ceases with time ; and relapses after a considerable interval are in 
all cases rare. For instance, syphilitic erythema, which usually 
appears about the sixth week after the development of the chancre, 



400 INTRODUCTORY REMARKS. 

may perhaps return as late as the eighth or ninth month, but never 
several years after the chancre. 

Ffnally, the same name is, in several instances, applied to symp- 
toms which are in reality distinct, and which are widely separated 
upon the syphilitic scale. Thus there is a form of alopecia which 
is one of the earliest general symptoms, and in which the hair is 
freely shed from the scalp and eyebrows, but may grow again, since 
the hair-bulbs are not seriously affected ; and there is another and 
rarer form, observed only in the later stages of syphilis, in which 
the whole integumental surface becomes permanently bald. Two 
forms of iritis, ecthyma, etc., are also observed at distinct periods ; 
but these constitute no exception to the law of succession of syphi- 
litic symptoms. 

We thus see that a simple chronological division of constitutional 
symptoms may be maintained ; but there are several objections to 
the additions made to this system by Eicord, as I shall proceed to 
show. 

In the first place, Eicord's statement that " secondary symptoms 
are not capable of inoculation," is true in the guarded sense in 
which it was intended, viz., that they are not inoculable upon the 
persons bearing them ; but the inference which was also designed to 
be conveyed, that they differ in this respect from a chancre, is not 
true, as Eicord himself has since acknowledged. Both are contagious 
and inoculable upon persons free from syphilitic taint, but neither 
are auto-inoculable. 

Again, Eicord's statements relative to tertiary symptoms cannot 
at the present day be implicitly received. This author maintains 
that tertiary lesions are not inoculable and cannot be transmitted by 
hereditary descent under their peculiar type, and hence that the 
virus in this stage must be entirely changed from its original 
character. The first of the above assertions is doubtful, the second 
incorrect. The inoculability of tertiary symptoms has never been 
tested upon persons free from syphilitic taint, and its possibility, 
therefore, may yet be demonstrated, as that of secondary symptoms 
has been. Their transmission by hereditary descent in a few 
instances, still preserving their peculiar type, is a known fact. The 
most frequent instance of this is the occurrence of syphilitic hepatitis 
and deep tubercles of the subcutaneous cellular tissue in infants 
affected with hereditary syphilis. Virchow 1 has also found small 

1 La Syphilis Constitutionnelle, traduit de l'AUemand par le Dr. Picard, Paris, 
1860, p. 4. 



CLASSIFICATION OF GENERAL SYMPTOMS. 401 

collections of the deposit peculiar to tertiary syphilis in the cerebral 
substance of children born of syphilitic mothers. 

Hunter attributed the difference in the situation of early and late 
general symptoms to the influence of cold, which, as he supposed, 
rendered the more superficial parts of the body most susceptible to, 
and earliest affected by the virus. This anatomical distinction, 
without Hunter's explanation, has been retained in Bicord's classifi- 
cation, in which the, skin and mucous membranes on the one hand, 
and the osseous, fibrous, and cellular tissues on the other, are 
regarded as the exclusive seat of secondary and tertiary manifesta- 
tions respectively. But this rule cannot always be maintained, 
since one of the earliest symptoms of general syphilis — preceding 
in many cases the eruption upon the skin — consists of pains resem- 
bling rheumatism, some of which are evidently seated in the peri- 
osteum (chiefly that of the cranium and in the .neighborhood of the 
joints), and this fibrous tissue has been known to take on acute 
inflammatory action at this time. In order to avoid this difficulty, 
Bassereau asserts that general syphilis attacks indifferently the 
integumental, fibrous, and osseous structures in all periods of the 
disease, but that the more superficial portions of each are affected in 
the earlier and the deeper in the later stages. 

Virchow 1 would exclude all consideration of situation from the 
classification of general symptoms, and has proposed a system based 
upon the nature of the pathological changes in the different lesions. 
but which is too widely at variance with the ideas at present 
received to meet with general adoption. Yon Baerensprung 2 offers 
a similar classification in which secondary symptoms are made to 
include those lesions which are characterized by hyperemia and 
simple exudation ; and tertiary symptoms* those in which there is 
tubercular deposit. 

But it is easier to pull down than it is to build up, and attempts 
in the latter direction may well be deferred until many preliminary 
points are settled. Meanwhile, we have every reason to be satisfied 
with the simple and natural chronological division which forms the 
basis of Eicord's classification, and which owes its excellence in a 
great measure to the keen powers of observation of this truly emi- 
nent surgeon. The few errors which he introduced are not essential 
to the system, and may well be forgotten, when we recollect his 
important contributions to our knowledge of the natural history of 
syphilis. 

1 Op. cit. 2 Annales de la Charity, vi., p. 56, et vii., p. 173. 

26 



402 



INTRODUCTORY REMARKS. 



The time of the appearance of any given syphilitic lesion will 
be influenced in a measure by the constitution of the patient, his 
mode of life, and the treatment to which he is or has been subjected, 
and can therefore be determined only approximatively. The fol- 
lowing table compiled by M. Martin 1 from the statistics of McCarthy, 
Bassereau, Sigmund, and Fournier, is, however, of value in exhibit- 
ing the usual period of development, following the appearance of 
the chancre, of the more important syphilitic symptoms : — 



SYMPTOMS. 



Roseola, ....... 

Papular eruption, ...... 

Mucous patches, ...... 

Secondary affections of the fauces, 

Vesicular eruption, ...... 

Pustular eruption, . . . . . 

Rupia, ........ 

Iritis, ........ 

Syphilitic sarcocele, 

Periostosis, ....... 

Tubercular eruption, ..... 

Serpiginous eruption, ..... 

Gummy tumors, ...... 

Onychia, . , 

True exostosis, 

Ostitis, changes in the bones and cartilages, . 
Perforation or destruction of the velum palati, 



Date of usual 
development. 



45th day. 
65th " 
70th " 
70th " 
90th " 
80th " 
2 years. 
6th month. 

12th " 
6th « 

3 to 5 years. 

3 to 5 " 

4 to 6 " 
4 to 6 " 
4 to 6 " 
3 to 4 " 
3 to 4 « 



Date of earliest 
development. 



25th day. 
28th « 
30th " 
50th " 
55th " 
45th " 

7th month. 
60th day. 

6th month. 

4th " 
3 years. 

3 " 

4 " 
3 " 
2 " 
2 « 
2 " 



Date of latest 
development. 



12th month. 
12th " 
18th « 
18th « 

6th « 

4 years. 

4 « 

13th month 

34th " 

2 years. 

20 " 

20 " 

15 " 

22 « 

20 « 

41 " 

20 " 



In most cases, when syphilis is abandoned to its natural course 
uninfluenced by treatment, the earliest general symptoms nearly or 
quite disappear spontaneously, and, after a time, are succeeded by 
another set, which, in its turn, may give place to a third, and so on ; 
the number of successive outbreaks varying in different cases, and 
commonly being in proportion to the intensity of the action of the 
virus. Thus syphilis usually shows itself not in a continuous, but 
in an interrupted succession of symptoms, — a fact of some impor- 
tance, because too often the reappearance of syphilitic manifestations 
is regarded as a relapse, while it is really but the natural course of 
the disease. # 

In the majority of cases, even in the absence of treatment, syphilis 
tends to self- limitation, and its symptoms ultimately cease to appear, 
leaving the patient in a fair state of health. 

For the demonstration of these two facts in the natural history of 
syphilis, we are chiefly indebted to Diday. 2 

' Del'Accident Primitif de la Syphilis Constitutionnelle, Paris, 1863, p. 87. 
2 Histoire Naturelle de la Syphilis. 



INITIAL LESION OF SYPHILIS. 403 



CHAPTER II. 

THE INITIAL LESION OF SYPHILIS, OR CHANCRE. 

As stated in the introduction to the present work, logical accuracy 
as well as simplicity and perspicuity of language require the aban- 
donment of the terms "hard," "indurated," and "infecting chancre," 
as applied to the initial lesion of syphilis, which should be called 
simply by the name of chancre, or primary syphilitic ulcer. If the 
name of "Hunterian chancre" be retained, it should be applied 
exclusively to the less frequent form of chancre which Hunter 
designated, and which is characterized, in addition to the induration 
common to all forms of chancre, by a degree of ulceration that 
involves the whole thickness of the skin or mucous membrane. The 
term "infecting chancre" is especially objectionable, as it implies 
that it is the chancre which infects, whereas the very development of 
this sore is the result of constitutional infection. As Diday remarks, 
when a man contracts syphilis, the only chancre that can properly 
be called infecting is the one upon the woman who gave him the 
disease. 

For a comparison of the frequency of the initial lesion of syphilis 
with that of the chancroid, the reader is referred to the first chapter 
of the second part of this work, where the remarks upon the seat 
of the chancroid are also applicable in the main to the sore under 
consideration. The following table exhibits the seat of 470 chancres, 
comprising all that were observed at the Hopital du Midi, in the 
year 1856. 

Chancres on the glans and prepuce 314 

M on the skin of the penis 60 

" ofl various parts of the penis . . . . . . 11 

" involving the meatus ........ 32 

" within the urethra (not visible on forced separation of the 
lips of the meatus, but recognized by palpation, inflam- 
mation of the lymphatics, etc.) ..... 17 

" on the scrotum and peno-scrotal angle . • . . 11 

" of the anus . 5 

M " lips 12 



•±04 INITIAL LESION OF SYPHILIS. 

Chancres of the tongue 3 

" " nose . . • . . " . • • • 1 

11 " pituitary membrane ...... 1 

" " fingers 1 

" " leg 1 

Total . . .470 

By comparing this table with the one upon page 336, it is seen 
that the seat of chancres is still more extensive than that of the 
chancroid, since it embraces the face and buccal cavity where the 
last mentioned ulcer is rarely, if ever, met with in practice, but 
where the syphilitic virus is often inoculated from a secondary 
lesion in the contact of mouth with mouth, etc. 

Has the chancre a period of incubation? This is an important 
question, since it involves two others of great practical interest: 
1. Whether the chancre is a local or constitutional lesion. 2. Whether 
its abortive treatment can prevent systemic infection. The solution 
of this question by experimentation is impracticable, since inoculation 
of a chancre upon persons already infected is in most cases impossi- 
ble, and upon healthy individuals unjustifiable. We can, therefore, 
refer only to clinical observation, and, even here, no slight difficulty 
is encountered. Patients may not come under observation until 
some days or weeks after contagion ; they have often had sexual 
connection repeatedly at short intervals ; and their statements as to 
the time of infection and the appearance of the chancre are not 
always reliable. But many careful observers have noticed the fact 
that, as a general rule, advice is sought at a later period for a 
chancre than for the chancroid, and the interval between contagion 
and the appearance of the ulcer is represented by patients as longer 
in the former than in the latter. Diday made minute inquiry of 
twenty-nine persons whose chancres were of recent origin; who 
appeared to be trustworthy, and certain of the facts which they 
stated; who had been exposed but once, and who had had no 
previous connection for at least a month, and found that the average 
interval between the sexual act and the appearance of the sore was 
fourteen days. 1 M. Chabalier, in an examination of ninety cases of 
chancre, found an average period of incubation of from fifteen to 
eighteen days; and states that the chancroid, on the contrary, is 
visible within thirty- six ^r forty-eight hours after contagion. 2 M. 
Clerc has especially insisted upon the presence of incubation as 
diagnostic of the chancre, and has reported several cases which 

i Gaz. Me*d. de Lyon, March 1, 1858. 
2 These de Paris, No. 52, 1860, p. 111. 



INITIAL LESION OF SYPHILIS. 405 

were preceded by a period of incubation of thirty days. I have 
myself met with very many cases in which the interval between a 
single exposure and the appearance of a chancre exceeded fourteen 
days, and in some there is every reason to believe that it has been 1 
of much longer duration. A gentleman of this city, of high social 
position, whom I know so intimately that I can vouch for the truth 
of his statements, visited Paris unaccompanied by his wife, and, 
while under the influence of wine, for the first time during fifteen 
years of married life had connection with a woman of the town. 
This was on the eve of his return to America, and his subsequent 
remorse and anxiety were so great that on his voyage home he 
examined himself daily with the greatest care to see if he had con- 
tracted any disease. His prepuce was very short, so that the glans 
was habitually uncovered and no lesion was likely to escape obser- 
vation, yet he found nothing until the day of his arrival home, the 
thirty-fifth after exposure, when he noticed a slight excoriation upon 
the internal surface of the prepuce. He showed it to his family 
physician, a Homoeopath, who told him that it was a mere abrasion 
which would heal in a few days, and that he might with safety have 
connection with his wife. As the promised cicatrization did not 
take place, on the fourth day after his arrival he applied to me, and 
I found a superficial chancre with well-marked parchment induration 
and attendant indurated ganglia. Since then he has had several 
attacks of general syphilis, and his wife, who was in the fifth month 
of pregnancy, contracted a chancre, had a syphilitic eruption, alo- 
pecia, iritis, etc., and gave birth to an infected child at term, which, 
under homoeopathic treatment, died at the age of one month. 

While writing these pages, my advice has been sought by a very 
intelligent physician, who was exposed but once to contagion on the 
night of August 16, and a well-marked chancre which he now bears 
upon the internal surface of the prepuce first appeared, September 1 ; 
making an interval of sixteen days. I have also at the present time 
under my care a merchant, who has been subject to herpes, and has 
been in the habit of watching his genital organs very closely after 
exposure. He now has a chancre, which he is positive did not show 
itself until five weeks after his last coitus. 

Castelnau reports a case communicated to him by the physician 
of a venereal hospital, who was himself the subject of the observa- 
tion, in which a chancre appeared thirty-three days after an impure 
intercourse. 1 

1 Annales des Maladies de la Peau et de la Syphilis, t. i., p. 212. 



406 INITIAL LESIOX OF SYPHILIS. 

But we have still more conclusive evidence of the incubation of 
the chancre in three cases in which the inoculated point was watched 
from day to day. The first is reported by Eollet. This surgeon, 
desirous of testing the character of a sore, inoculated its secretion 
without success upon the person bearing it. He then repeated the 
inoculation upon several persons who were affected with syphilis, 
and with the same negative result. This was previous to the disco- 
very of the fact that the chancre is not auto-inoculable ; hence Eollet 
believed it safe to inoculate the secretion of the same sore upon still 
another individual, who was free from syphilis, although affected 
with chancroids and a suppurating bubo. The inoculation proved 
successful, and gave rise to a chancre, which did not make its appear- 
ance until the eighteenth day. 1 In two other cases of artificial inocu- 
lation of a chancre, one performed by Einecker and the other by 
Gibert, the period of incubation was 25 and 24 days respectively. 

When speaking of the abortive treatment of chancres, I shall also 
adduce facts to show that destructive cauterization of a chancre, at a 
very early period of its existence, does not prevent secondary symp- 
toms, and hence that the system must be regarded as infected from 
the first. Moreover, the analogy of other infectious diseases, as 
vaccinia, glanders, etc., leads us to infer that the absorption of the 
syphilitic virus is instantaneous. 

In short, there can be no question at the present day that the 
initial lesion of syphilis, as of other infectious diseases, possesses a 
period of incubation. So far as we can now determine, this period 
is, upon an average, of from two to three weeks' duration, and may 
undoubtedly extend to five or even six weeks. To ascertain its 
shortest limit is attended with more difficulty, since the virus is 
sometimes deposited in a wound or abrasion occurring at the time 
of coitus, and, in consequence of inattention to cleanliness or other 
accidental causes, remaining open until the development of the 
chancre, so that it is impossible to say precisely when the simple is 
transferred into the specific ulcer. The inoculation of the same 
point with the chancroidal and syphilitic poison will also explain 
why in some instances the initial lesion of syphilis appears to be 
developed in some cases earlier than in others, since the action of 
the former virus commences at once and gives rise to an ulcer which 
may be perceived by the patient in the course of two or three days, 
and which masks the later development of the chancre. 

The following table, prepared by M. Bassereau, 2 of the chancres 

» Archives G6n. de MeU, Avril, 1859, p. 409. 2 Qp_ c i t ^ p i 40 



INITIAL LESION OF SYPHILIS. 407 

which preceded 170 cases of syphilitic erythema, will indicate the 
various forms which a chancre may assume, and afford some idea of 
the comparative frequency of these forms in the milder cases of the 
disease, of which the more severe instances exhibit a larger propor- 
tion of excavated ulcers : — 

Superficial erosions 146 

Circumscribed ulcers, with abrupt edges, involving the whole thickness of the 

skin or mucous membrane .......... 14 

Circumscribed phagedenic ulcers, with a pultaceous floor, involving the tissues 

a short distance beyond the skin or mucous membrane .... 10 



Total 170 

It appears from this table that the chancre has no exclusive form, 
but that it most frequently assumes one which differs widely from 
the chancre-type as heretofore described by most authors. The 
frequency of the superficial form of chancre excited my attention 
several years before I had met with any description of it in books, 
and the first cases which came under my notice were mistaken for 
mere abrasions until the appearance of secondary symptoms corrected 
the diagnosis. Within the last year, a physician, well instructed in 
the literature of venereal, applied to me with a. superficial chancre 
so closely resembling a simple abrasion that I could not persuade 
him of its specific character, and therefore advised him to examine 
the woman with whom he had had connection and see if she did not 
present symptoms of syphilis. A few weeks after, they both called 
at my office ; the physician, with syphilitic erythema ; his mistress, 
with syphilitic papulae. 

The superficial form of chancre is most marked on the internal 
surface of the prepuce, by which it is protected from the air and 
friction, and kept free from scabs ; and it is in this situation that I 
have most frequently met with it. It has generally a circular or 
ovoid, but sometimes irregular, outline. Its floor is but slightly, if 
at all, excavated, and occasionally is even elevated above the sur- 
rounding integument by the subjacent induration. Its surface is 
smooth, often looking as if polished, destitute of the consistent and 
adherent exudation of the chancroid, and of a red or grayish color. 
Its secretion is. a clear serum — free from pus-globules, unless the 
sore has been irritated — which may often be seen issuing from 
minute pores, after the previous moisture has been wiped away. It 
has no surrounding areola, and leaves no cicatrix to mark its site 
Barely one-third of the chancres in Bassereau's 170 cases, left airy 
visible trace aside from induration. When situated upon the ex- 



408 INITIAL LESION OF SYPHILIS. 

ternal integument, as the sheath of the penis — where most venereal 
ulcers are chancres — and exposed to the air, it becomes covered 
with scabs, which give it the appearance of a pustule of ecthyma, 
or a patch of scaly eruption, and which may readily lead to an error 
in diagnosis. The characters of the chancrous erosion are also 
modified by the application of irritants, or by a want of cleanliness ; 
its secretion may become purulent, and its surface resemble that of 
the chancroid; but its normal' appearance may.be restored by apply- 
ing a water-dressing for a few days. 

Frequent as is the chancrous erosion, it must not be regarded as 
the exclusive form of chancre. Diday believes that it is due to 
inoculation from a secondary, and that the excavated chancre is 
produced by inoculation from a primary lesion. Between this form 
and the indurated excavated ulcer, known as the Hunterian chancre 
— which was so long and so erroneously supposed to be the especial 
harbinger of general syphilis — there may exist many gradations 
which it is unnecessary to describe in detail. Ulcerative action 
may, though rarely, go beyond this point, and terminate in phage- 
dena ; but, generally, it is limited by the plastic inflammation of the 
surrounding tissues, as is evident from an examination of the edges 
of nearly all the forms of chancre, which are sloping, somewhat 
prominent, and adherent, unlike the abrupt and detached margins 
of the chancroid. 

We have seen that inoculation of the secretion of the chancroid 
produces at first a pustule ; the earliest appearance of the initial 
lesion of syphilis on the contrary is in the form of a papule, which 
takes on superficial ulceration, increases in breadth and thickness, 
and is but slightly excavated, or frequently is elevated above the 
surrounding surface. 

In experimental inoculation of the syphilitic virus, the lengthy 
incubation of the chancre should not be forgotten, nor the result be 
pronounced negative until after the lapse of at least six weeks with- 
out the appearance of a sore. 

We have yet to consider those characters which are common to 
all the forms of chancre. 

Induration was recognized at a very early period in the history of 
syphilis by John de Vigo, 1 Gabriel Fallopius, 2 Leonard Botal, 3 and 

1 "Nam ejus origo in partibus genitalibus, videlicet in vulva in mulieribus et in 
virga in hominibus, semper fuit cum pustulis parvis, interclum lividi coloris, ali- 
quando nigri, non nunquam subalbidi, cum callositate eas circumdante." (John db 
Vigo, Practica copiosa in Arte Chirurgica, etc. Rome, 1514, lib. v.) 

2 Tractatus de Morbo Gallico, Pat avium, 1564. 

3 Luis Venerea Curandae Ratio, Paris, 1503. 



INITIAL LESION OF SYPHILIS. 409 

Ambrose Pare, 1 as a prominent symptom of the sore which pre- 
cedes general syphilis; nearly forgotten by subsequent writers, 
though occasionally mentioned, as by Nicholas Blegny, 2 it has again 
assumed importance in modern times from the teachings of Hunter, 3 
Bell, 4 and especially Eicord, and is now justly regarded as the most 
characteristic feature of a chancre, when seated upon a person exempt 
from previous syphilitic taint. 

The induration of a chancre is a peculiar hardness of the tissues 
around and beneath the sore. Simple inflammation may occasion 
an effusion of plastic material and consequent engorgement about 
any sore ; but specific induration is of an entirely distinct character. 
The latter is formed, as the French say, " a froid" that is, without 
inflammatory action ; the deposit takes place in the absence of all 
the symptoms of inflammation, "pain, heat, redness, and swelling;" 
and so silently, so insidiously, tjiat the patient is often ignorant of 
its presence, or discovers it only by accident. No event is more 
common than for a surgeon to be consulted by a man who states 
that he had a sore a few weeks ago, "which did not amount to 
much ; " he " burnt it with caustic and it healed up ; " but he has 
recently found that it left a "lump" behind it. This "lump" is 
specific induration and denotes that the constitution is infected. A 
gentleman recently applied to me -for phymosis — neither congenital 
nor inflammatory, which occasioned no inconvenience except an 
inability to retract the prepuce. He was not aware that he had had 
any venereal trouble, but, on examination of the parts, a mass of 
induration as large as an almond was perceptible to the touch and 
almost to the sight — so great were its dimensions — situated about 
the furrow at the base of the gians. The phymosis was simply due 
to the mechanical obstruction presented by the induration to the 
retraction of the prepuce, and this difficulty alone induced him to 
seek advice. Frequently, also, patients apply to a surgeon for treat- 
merit for general syphilis, and honestly declare that they have 
never had a chancre, though the previous existence of such, and 
even its very site, are unmistakably indicated by the remaining 
induration. 

Again, specific induration and inflammatory engorgement differ 
in their objective symptoms. The boundaries of the former are 

1 "S'il y a ulcere a la verge et s'il demeure durete au lieu, telle chose infallible- 
ment montre le malade avoir la variole." (Park's works, first published at Paris, 
1575, Book 19th.) 

2 L'Art de Guerir les Maladies Vengriennes, etc., Paris, 1673. 

3 Ricord and Hunter on Venereal; 2d Am. edition, Phil., 1859, p. 286. 

* Treatise on Gonorrhoea Virulenta and Lues Venerea, London, 1793, vol. ii., p. 19 



410 INITIAL LESION OF SYPHILIS. 

clearly defined, while the extent of the latter cannot be limited with 
nicety ; the one terminates abruptly, the other shades gradually into 
the normal suppleness of the part ; the first is freely movable upon, 
the second adherent to, the tissues beneath. The difference in the 
sensations they impart to the fingers is still greater ; specific indu- 
ration is so firm, hard, and resistant, that it is often compared to a 
"split-pea" 1 or mass of cartilage; the softer and doughy feel of 
common inflammatory engorgement requires no description. It is 
hardly necessary to say that there is no incompatibility between 
these two pathological conditions which can prevent their co-exist- 
ence, and hence arises, in some few cases, a difficulty of diagnosis. 
The effect of simple inflammation, however, subsides in a few days, 
or in a week or two at farthest, and lays bare the specific induration, 
which may, for a time, have been buried beneath it ; and under all 
circumstances reference may be made to the neighboring ganglia, 
the induration of which is equally constant and significative with 
that of the chancre. 

In the masses of induration of considerable size to which the above 
description chiefly refers, the adventitious deposit occupies the skin 
or mucous membrane bordering upon the edges of the sore, and also 
the cellular tissue beneath it. There is another, but less common 
form of induration in which the -deposit is confined to the mucous 
membrane alone, and does not involve the cellular tissue beneath. 
It most frequently occurs in connection with the superficial chancre, 
and is called the " parchment-induration " because it imparts to the 
fingers a sensation as if the erosion rested upon a thin layer of that 
material. Eeadily perceived in most cases, in others it may escape 
notice, especially to one not familiar with it. 

The situation of the chancre influences to a certain extent the 
degree of development of the induration; which, for instance, is 
generally but slightly marked and of the parchment variety upon 
the walls of the vagina and the margin of the anus ; while, 01? the 
contrary, it is fully developed in the furrow at the base of the glans 
and upon the lips. Some authorities have gone so far as to maintain 
that induration is entirely dependent upon the seat of the sore, and 
have instanced the uniformity with which all venereal ulcers upon 
the lips are indurated, in proof; but, as before stated, this objection 

1 Benjamin Bell usually has the credit of the comparison of induration to a split- 
pea, but reference to his work shows that he uses the term as indicative of the size 
of a chancre, and not of the consistency of its base. He says: "A real venereal 
chancre is seldom so large as the base of a split-pea, and the edges of the sore are 
elevated, somewhat hard, and painful." Op. cit., vol. i., p. 19. 



INITIAL LESION OF SYPHILIS. 411 

to a duality of venereal poisons lias been effectually exploded by 
recent experimental inoculations, in which chancroids with a per 
fectly soft base have been developed upon the region in question. 

Eicord believes that the development of induration corresponds 
with the supply of lymphatic vessels ; that the former is most marked 
where the latter are most abundant ; and that the induration, in fact, 
consists in an inflammation of the capillary absorbents with effusion 
into the intervening tissue. 1 The tendency of induration to invade 
the lymphatic system favors this opinion, which, however, has not 
been corroborated, to my Knowledge, by the necessary anatomical in- 
vestigations. Those microscopists 2 who have examined the histology 
of induration concur in stating that it is composed of fibro-plastic 
elements — fusiform bodies, nucleated cells, free nuclei, and amorphous 
matter — infiltrating the layers of the derma and subcutaneous tissue, 
without any special characters to distinguish it from similar products 
of non-specific origin. These elements are not found in the secretion 
of the sore. 

Eicord, to whose careful investigations I am indebted for a large 
part of the present section, has endeavored to determine the limits 
of time within which induration may take place. He states that it 
occurs most frequently during the first or second week after conta- 
gion ; never before the third day, nor after the third week ; that, 
consequently, if a sore is to be indurated at all, it will be so by the 
twenty-first day after the sexual act in which it originated. It is 
with great reluctance and hesitation that I dissent from so accurate 
an observer, but believing as I do in the incubation of the chancre, I 
cannot but think that this subject requires renewed investigation 
with the additional light we now possess. I believe it would be 
nearer the truth to substitute the words " after the appearance of the 
chancre" in place of "after contagion." Taking the former as the 
starting point, there can be no question that induration occurs within 
a v5ry few days ; I have almost invariably met with it during the 
first week, and should not hesitate to regard its absence, at the ter- 
mination of three weeks, both in the sore itself and in the neigh- 
boring ganglia, as indicative that the patient was safe from constitu- 
tional infection. 

Sigmund, 3 of Vienna, gives the following table of the dates after 

1 Lemons sur le Chancre, p. 86. ♦ 

2 Robin et Marchal de Calvi, Elements Caracteristiques du Tissu Fibro-plastique 
et sur la Presence de ce -Tissu dans l'lnduration du Chancre. Seance de l'Acade'mie 
des Sciences, Nov. 2, 1846. Lebert, Traits d'Anatomie Pathologique, vol. ii. 

3 British and For. Med.-Chir. Rev., Jan., 1857, p. 206; from the Wien Wochen^ 
echrift, No. 18. 



412 INITIAL LESION OF SYPHILIS. 

contagion at which, induration was first detected in 261 cases of 
chancres. 

On the 9th day in 71 cases. 

« 10th " '. 84 " 

" 14th " 76 " 

» 17th " 15 " 

" 19th " 12 " 

" 21st " 3 " 

Mr. Babington, the English editor of Hunter on Venereal, advanced 
an opinion which has been adopted by a few authors, that induration 
may take place before the appearance of the chancre ; but experience 
does not confirm this statement. After all, if it be admitted that all 
possible mischief is accomplished long before the chancre first ap- 
pears, the exact date of the evolution of the induration possesses 
less practical importance than it assumed under the supposition that 
it marked the boundary line between local and constitutional syphilis. 

Specific induration usually remains for a long time after the cica- 
trization of the chancre, and, unless dissipated by treatment, may, in 
most cases, be felt for at least two or three months, and often longer. 
Some statistics collected by M. Puche show that its persistency be- 
comes rarer after the third month, and is quite exceptional after the 
eighth, though this surgeon reports thirteen cases in which it was 
perceptible from 390 to 2062 days after contagion ; in nine of the 
thirteen, the induration occupied the furrow at the base of the glans, 
a favorite seat for its full development and long persistency. M. 
Puche met with still another instance in which induration persisted 
for nine years. I have met with several cases of two and three years' 
duration, and Eicord with one of thirty years. It follows from the 
above data that induration is an early symptom of syphilis, and that 
the time within which its presence or absence is of diagnostic value 
is limited, though variable in different cases. 

Induration is sometimes much shorter lived ; the parchment form 
especially, according to Eicord, may entirely disappear before the 
chancre heals, and the cicatrix present as soft a base as the chancroid. 
This form of induration is, however, in many instances, as durable 
as any other. 

As the process of absorption goes on, the indurated mass becomes 
less firm and resistent, and gradually softens until it can finally no 
longer be detected. Occasionally a relapse takes place in which it 
resumes its original characters. I have seen such accompany a re- 
newed outbreak of a syphilitic eruption; while, in other instances, 



INITIAL LESION OF SYPHILIS. 413 

the exciting cause has appeared to be some local irritation, as a chan- 
croid, vegetation, etc. 

Unlike the chancroid, the chancre is rarely met with in groups 
of two or more upon the same subject. Of 456 patients, under the 
observation of Fournier at the Hopital du Midi, 226 had but one 
and 115 several chancres ; of the latter 86 had two, 20 had three, 5 
had four, 2 had five, 1 had six, and 1 had nineteen. Debauge col- 
lected 60 cases at the Antiquaille Hospital, at Lyons, in 41 of which 
there was a single chancre,, and in 19 several. 1 These statistics would 
show that the chancre is solitary in three cases to one in which it is 
multiple. The ratio is still greater in M. Clerc's observations, in 
which the chancre was single in 224 out of 267 cases. If multiple 
at all, it is almost alwaj^s true that they are so as the immediate effect 
of contagion, and because several rents or abrasions were inoculated 
together in the sexual act. If solitary at first, they continue to be 
so ; since successive chancres rarely spring up in the neighborhood, 
as in the case of the chancroid, owing to the fact that the virus ceases 
to act upon the system as soon as it is once infected. This explana- 
tion is alone sufficient, without calling in the aid, as Eicord does, of 
the paucity of the secretion, which is copious enough to inoculate 
sound persons. . ' 

The insidious manner in which induration takes place characterizes 
the whole development of the chancre, and it is not surprising that 
it often exists for some time before it is perceived by the patient, or 
escapes notice entirely. The explanation of many "bubons d'em- 
blee" and supposed cases of syphilis without chancre is evident. 
Unfortunately the profession has been too prone to go to extremes 
in taking the testimony of venereal patients : by some their state- 
ments are received implicitly ; by others they are as constantly dis- 
believed; while few draw the distinction between honesty and 
ignorance, necessarily arising from want of experience, and the ab- 
sence of medical knowledge. 

The secretion from a chancre is much less copious than that from 
the chancroid. This difference is especially evident in the superficial 
erosion, but is also perceptible in the excavated forms, the discharge 
from which is less free and purulent than in the chancroid. 

Numerous experiments show that the immunity conferred by one 
attack of syphilis extends in most cases even to the initiatory sore. 
This fact was first announced 'by M. Clerc in 1855. Fournier inocu- 
lated the discharge of ninety-nine chancres upon the patients them- 

1 Op. cit., p. 6. 



414 INITIAL LESION OF SYPHILIS. 

selves, and succeeded in but one, in whom the experiment was 
performed within a very short period after contagion. M. Puche 
states as the result of his own experiments that auto -inoculation of 
the chancre is successful in only two per cent. Poisson obtained like 
results in fifty-two cases, 1 and Laroyenne was unsuccessful in every 
one of nineteen. 2 Do not these facts tend to show that the chancre 
is from the very first a constitutional lesion ? Their bearing upon 
the use of artificial inoculation as a means of diagnosis is evident ; 
failure favoring the supposition that the sore is a chancre. 

Whenever auto-inoculation has proved successful, it has been with 
virus taken from the sore at a very early period of its existence. In 
the same manner vaccine lymph may be successfully reinoculated 
within a day or two after the first appearance of the future pustule, 
while if the attempt be deferred until its full development, it will 
fail. Hence we infer, that although absorption is- instantaneous and 
general infection is inevitable from the first, yet that time is requisite 
to bring the system fully under the influence of the virus. 

Mr. Henry Lee, of London, as early as 1856, also called attention 
to the difficulty of inoculating chancres, or " syphilitic sores affected 
with specific adhesive inflammation," upon the persons bearing 
them. 9 This surgeon has since maintained that if a chancre — the 
discharge from which, under ordinary circumstances, he believes to 
be destitute of pus-globules — be irritated, as by the application of a 
blister or ung. sabinse, until its secretion becomes purulent, it is 
susceptible of inoculation.* Mr. Lee's experiments require confirma- 
tion before coming to any conclusion regarding them. It is difficult • 
to believe that in the numerous French observations the sores had 
always escaped irritation and that the discharge was invariably 
serous. 

The difficulty of inoculating the secretion of a chancre is equally 
as great upon a person who has arrived at the stage of secondary 
syphilis as upon one who has but recently been affected. 

The chancre, as a general rule, is of somewhat shorter duration 
than the chancroid, but often remains until after the appearance of 
secondary symptoms — a remark which I should not think it neces- 
sary to make had I not met with persons who supposed that primary 
syphilis must terminate before secondary commenced I Of 97 cases 
observed by Bassereau, in which no treatment had been employed, 

1 Lemons sur le Chancre, p. 274. 
1 Annuaire de la Syphilis, annde 1858, p. 241. 
s British and For. Med.-Chir. llev., Oct., 1856. 
* Ibid, for April, 1859. 



INITIAL LESION OF SYPHILIS. 415 

syphilitic erythema, one of the earliest general symptoms, occurred 
in 58 before, in 18 during, and in 21 after the cicatrization of the 
chancre. 1 

Phagedena generally spares the chancre or limits its ravages to the 
destruction of the surrounding induration. In rare instances, how- 
ever, an extensive phagedenic ulcer is the initial lesion of syphilis, 
and, in this case, the subsequent general symptoms are usually of 
an aggravated character. Babiugton says : " The secondary symp- 
toms which follow the phagedenic sore are peculiarly severe and 
intractable. They commonly consist of rupia, sloughing of the 
throat, ulceration of the nose, severe and obstinate muscular pains, 
and afterwards inflammation of the periosteum and bones. Similar 
complaints will follow the ordinary chancre ; but when they follow 
a phagedenic sore they are very difficult to be cured ; and it is not 
uncommon that the constitution of the patient should at length give 
way under them, and that the case should terminate fatally." 2 

Bassereau also found a correspondence between the severity of 
the chancre and that of the syphilitic eruption. Thus, of 68 chan- 
cres which preceded a pustular syphilide, 20 were phagedenic and 
4 others serpiginous ; 3 and 18 of 50 chancres followed by a tuber- 
cular eruption produced destruction of the tissues to a greater or 
less extent. It will be recollected, on the contrary, that 143 of 170 
chancres followed by syphilitic erythema were mere erosions, and 
that 10 only exhibited a very slight tendency to phagedena. Basse- 
reau states that a similar relation exists between the primary sore 
and other syphilitic lesions, and lays down the rule, that "mild 
syphilitic eruptions and, in general, those constitutional symptoms 
which exhibit but little tendency to suppurate, follow the mild 
forms of chancre ; while pustular eruptions, and, at a later period, 
ulcerative affections of the skin, exostoses terminating in suppura- 
tion, necroses, and caries, follow phagedenic chancres." The degree 
of ulceration of the chancre is also regarded by Diday 4 as one of 
the most valuable indications to enable us to determine whether the 
attack of syphilis is to be mild or severe, and whether mercury can 
or cannot be dispensed with in the treatment. Admitting the truth 
of this rule, it does not follow that the condition of the chancre in 
any manner determines the severity of subsequent symptoms, but 
merely that it is an indication of the activity of the virus and of 
the state of the patient's system — the two causes upon which the 
severity of the attack chiefly depends. 

1 Op. cit., p. 180. 2 Ricord and Hunter on Venereal, 2d ed., p 351. 

8 Op, cit., p. 442. * Histoire Naturelle de la Syphilis, p. 84. 



416 INITIAL LESION OF SYPHILIS. 

A chancre situated upon the external integument, as the sheath 
of the penis, often leaves a peculiar discoloration of the skin of a 
sombre brown or brownish-red color, which is never seen after the 
chancroid ; in time its dark hue fades into a white. An instance of 
this kind is figured by Eicord in his Iconographie des Maladies 
Veneriennes, pi. xviii. 

Eicord first called attention to the fact, which has since been 
verified by many observers, that a chancre during the reparative 
period may be transformed into a mucous patch, and thus a primary 
be changed into a secondary lesion. This transformation may take 
place upon any part of the body whether of skin or mucous 
membrane, but more frequently upon the latter, especially when 
habitually in contact with an opposed surface, whereby heat and 
moisture are maintained ; as, for instance, upon the internal surface 
of the prepuce and labia majora, and upon the lips and tongue. 
Davasse and Deville have carefully studied the progressive changes 
by which this process is accomplished. 1 The surface of the chancre 
loses its grayish aspect and fills up with florid granulations, com- 
mencing at the circumference, as in the ordinary period of repair ; 
but just as these changes are reaching the centre of the sore, a nar- 
row white border of plastic material appears around its margin, and 
extending towards the centre, finally covers it with the membranous 
pellicle which is characteristic of a mucous patch. If the patient 
does not come under observation until these changes have been 
effected, the initial lesion of his disease may be supposed to be a 
mucous patch instead of a chancre. 

We have already seen that most chancroids are free from gangli- 
onic reaction, and that when this occurs it is always inflammatory 
and chiefly involves one ganglion, which tends to suppuration and 
often furnishes inoculable pus. The chancre, on the contrary, gives 
rise to changes in the neighboring lymphatic ganglia, which, by 
their constancy and the peculiarity of their symptoms, are of the 
highest value in diagnosis. A number of these bodies become 
enlarged and indurated in a similar manner to the base of the chan- 
cre, without inflammatory action ; they do not suppurate except in 
rare instances, and the pus is never inoculable. The induration of 
the neighboring ganglia, attendant upon a chancre, will be more 
fully described in the next chapter. 

Diagnosis of the Chancre. — For much that relates to the diag- 
nosis of the initial lesion of syphilis, the reader is referred to the 

1 Etudes Cliniques des Maladies Ve"ndriennes ; des Plaques Muqueuses. Arch. 
G6n. de Me*d., 4e s6rie, vol. ix., p. 182. 



INITIAL LESION OF SYPHILIS. 417 

remarks and the diagnostic table in a preceding chapter concerning 
the chancroid (p. 347). 

The most valuable diagnostic signs of a chancre are its period of 
incubation, the induration of its base, and the induration of the 
neighboring ganglia. Both of the latter are rarely, if ever, wanting. 
Of the two, I believe induration of the ganglia to be the more con- 
stant. Absence of induration of the base cannot always be depended 
upon, even according to Eicord's showing, who says that this symp- 
tom sometimes disappears after a few days' duration, and it ma*y, 
therefore, have passed away before the patient comes under the care 
of the surgeon. Cases are reported by competent observers of 
chancres with a perfectly soft base, which have yet been followed 
by general syphilis; such instances, however, are extremely rare. 
If a caustic or astringent has recently been applied to a sore, indu- 
ration of its base should be admitted with caution : examine the 
condition of the neighboring ganglia; direct simple applications 
only for a week or two, and see if the hardness persists. Inflam- 
mation of the surrounding tissues may counterfeit or mask specific 
induration: here, again, refer to the ganglia, or defer the diag- 
nosis until the inflammatory products shall have time to undergo 
absorption. 

Even admitting that cases may possibly occur in which induration 
of the base and of the ganglia are both absent, yet these two promi- 
nent symptoms of a chancre are as constant and as valuable as any 
others in the whole range of pathology: more than this we can 
neither ask nor expect. Since absorption of the syphilitic virus 
takes place instantaneously so soon as it has penetrated beneath the 
epidermis, and since there is, therefore, no opportunity of preventing 
constitutional infection by abortive' treatment, there is less necessity 
for an early diagnosis than was formerly supposed ; and, in obscure 
cases, we may wait, if necessary, until after the time within which, 
if ever, secondary symptoms invariably appear. 

The superficial form of chancre does not differ materially in 
appearance from a common excoriation, or from the superficial 
ulcerations of balanitis ; it may be distinguished by its late appear- 
ance after exposure, its induration, and greater persistency. No 
suspicion of a chancre, however, may be awakened if the erosion be 
surrounded by simple inflammation of the mucous membrane, unless 
the induration of the inguinal ganglia be discovered, and hence the 
condition of these bodies should always be examined in apparent 
cases of balanitis. 

Inoculation of the secretion of a sore upon the person bearing ij 

27 



418 INITIAL LESION OF SYPHILIS. 

is an unfailing test of a chancroid, but of no value in the diagnosis 
of chancres. 

Urethral Chancre. — When a chancre is seated within the urethra 
beyond the field of vision, it may readily escape detection, and the 
case be mistaken for one of gonorrhoea. There are certain phe- 
nomena in an apparent case of gonorrhoea which should lead the 
surgeon to suspect and search for a urethral chancre ; and these arcs 
a small amount of discharge, which is chiefly watery and mixed 
with blood, and the location of the pain, especially during the passage 
of the urine, at a fixed point. The specific induration which sur- 
rounds the sore is generally perceptible to the touch ; the glands of 
the groin present their characteristic changes ; and a hard, indurated 
cord (induration of the lymphatics) may sometimes be felt extending 
from the seat of the chancre towards the root of the penis. The 
induration of a urethral chancre should be distinguished from the 
inflammatory engorgement of the chancroid, and from the hardness 
due to an inflamed follicle sometimes met with in gonorrhoea. 
Inflammatory engorgement is more diffused, less accurately defined, 
and more transient than specific induration, and is also attended by 
pain and tenderness on pressure. In doubtful cases the condition 
of the inguinal ganglia will almost always be sufficient to establish 
the diagnosis. 

Chancres about the Mouth. — Chancres of the lips are generally 
superficial, and very rarely excavated unless subjected to irritation. 
Their outline is ovoid, the longer axis parallel to the buccal fissure, 
and their general aspect is the same as that of the superficial 
chancre, to which variety they belong. When they involve the 
labial commissure they are divided into two portions, separated by 
a deep ulcerated fissure at the angle of the mouth. 

Chancres upon the tongue are most frequent near its extremity. 
They are generally of small size, and are more deeply excavated 
than those upon the lips. Chancres have also been observed upon 
the gums, internal surface of the cheeks, palate, and tonsils. 

Induration is nowhere more fully developed than upon the lips, 
except, perhaps, in the balano-preputial furrow; and is often so 
massive as to cause the lip to protrude and disfigure the countenance. 
It is less marked at the angle of the mouth, upon the tono-ue etc. 
though it may usually be detected without difficulty. The parch- 
ment form of induration is also met with upon this region in some 
instances. 

The ganglia connected with the seat of the sore by means of the 
lymphatic vessels take on induration, as in chancres upon other parts 



TREATMENT. 419 

of the body ; and, in most cases, they belong either to the anterior 
or posterior sub-maxillary groups. 

Phagedena is a rare complication of the buccal chancre. A single 
instance was observed at Cullerier's clinique, in which irritant 
applications had caused the ulcer to extend until it involved one-half 
of the lower lip and the inferior half of the cheek. 1 

Treatment op the Chancre. — It was formerly supposed that a 
chancre was at first a mere local affection, and that the general cir- 
culation did not become contaminated until some days after the 
appearance of the ulcer; and hence that its early and complete 
destruction was capable of averting infection of the constitution. 
The advice was therefore given to cauterize a chancre as soon as it 
appeared, and we were told that if the caustic was sufficiently power- 
ful to kill the tissues to an extent exceeding the sphere of specific 
influence of the virus, that a simple wound would be left after the 
fall of the eschar, and our patient would be preserved from syphilitic 
infection. This treatment, known as the "abortive treatment of 
chancre," was supported by the distinguished names of Eicord and 
Sigmund, who assigned the fourth day after contagion as the limit 
within which destructive cauterization could be employed with a 
certainty of success. 

Belief in the efficacy of this treatment is no longer admissible, 
and never could have been once entertained, had it not been for 
confounding the chancroid and syphilis, whereby surgeons were led 
to believe that when a patient whose chancroid had been cauterized 
escaped general syphilis, post hoc ergo propter hoc, his immunity was 
due to the cauterization. 

A chancre is never a mere local lesion, as is proved by its period 
of incubation, by the analogy of other morbid poisons, and by the 
fact, as shown by repeated experiments, that its destruction within 
a few days and even a few hours after its appearance, fails to avert 
constitutional infection. 

The average duration of the incubation of a chancre is from two 
to three weeks. During this period the inoculated point remains in 
a state of quiescence and exhibits no traces of inflammation ; hence 
the subsequent appearance of the chancre can only be ascribed to 
the reaction of the absorbed virus. It may be remarked, in passing, 
that this period of incubation renders the conditions of the so-called 
abortive treatment (cauterization within four days after contagion) 

1 Buzenet, Du Chancre de la Bouche, etc., These de Paris, 1858. 



420 INITIAL LESION OF SYPHILIS. 

impracticable, since the sore very rarely appears until the time 
specified has elapsed ; and the same consideration increases the prob • 
ability that Eicord and Sigmund, in their "thousands" of supposed 
successful cases, really applied the method only to the chancroid. 
Experiments with other morbid poisons prove that absorption is 
almost instantaneous. Bousquet inoculated the vaccine virus, and 
immediately applied cups and washed the part with chlorinated 
water without preventing the evolution of a pustule. 1 Kenault, 
Surgeon of the Yeterinary School at Alfort, inoculated horses with 
acute glanders, excised the part and applied the actual cautery one 
hour afterwards, yet the animals died of the disease. 2 Similar ex- 
periments with the sheep-pox virus proved • that its absorption does 
not require more than five minutes. Hence analogy would show 
that the syphilitic virus also reaches the general circulation almost 
instantaneously after its implantation beneath the epidermis. 

We have still farther the evidence of direct experiment. Numer- 
ous cases are recorded in which destructive cauterization within a 
few days, and even a few hours after the development of the chancre, has 
failed to avert constitutional infection. Diday has thoroughly cauter- 
ized chancres four days and a half and others five days after coitus, 
and secondary symptoms have still appeared. In another case, 
occurring in a patient who had watched himself with the greatest 
care from day to day and almost from hour to hour, the chancre 
was not developed until a month after the sexual act, but the abor- 
tive treatment was applied within six hours of its first appearance ; 
the sore healed in the course of three days, but -secondary symptoms 
appeared three weeks afterwards. 3 More recently, 4 Diday has reported 
several additional cases as follows : — 

Case 1. A man, aged 45, somewhat of a syphilophobist, and conse- 
quently very attentive to the condition of his genital organs, con- 
sulted Diday, Sept. 24th, 1858, for a chancre which he had first 
observed three days before. The sore was at once cauterized with 
the paste of vegetable carbon and sulphuric acid, in use at the 
Hopital du Midi. 

The patient was seen again Oct. 3, when the chancre was found to 
have healed and to have left a healthy-looking cicatrix. Slight in- 
duration of a few ganglia in the groins inspired, however some 
doubts as to the future. 

1 Traits de la Vaccine. 2 Acade'mie des Sciences 1849. 

» Gaz. MeU de Lyon, March 1, 1858. 

4 Annuaire de la Syphilis, annee 1858, p. 134. 



TREATMENT. 421 

Nov. 8. The cicatrix presented a well-marked mass of induration, 
and the glands of both groins were also evidently indurated; and the 
patient complained of scabs in his hair. 

Nov. 19. A papular eruption of a decided copper color appeared 
over the whole body. 

Case 2. A young man who had been subject to herpes prseputialis, 
and who had been in the habit of consulting his physician for each 
renewed attack, presented himself, Sept. '21, 1858, with a small 
chancre upon the integument of the penis, which had existed but 
two days only. Canquoin's paste was at' once applied and left on the 
ulcer for two hours. 

A week after, he was apparently well, but a slight hardness, like a 
grain of millet seed, felt when the cicatrix was pressed between the 
fingers, rendered the prognosis somewhat doubtful. 

Oct. 27. Syphilitic roseola began to appear upon the abdomen, and 
by Nov. 4, became general and unmistakable. The patient also had 
acne capitis, engorgement of the cervical ganglia, headache, etc. 

Case 3. A young man, who, from former experience, was familiar 
with the appearance of chancres, sought advice Oct. 14, 1858, for a 
small abrasion, which, as he stated, appeared only twenty-four hours 
before. It was immediately burnt with the carbo-sulphuric paste. 

Oct. 28. The sore had cicatrized but had left well-marked indu- 
ration, which also involved the inguinal ganglia. 

Nov. 26. He presented a papular syphilitic eruption, and scabs 
upon the hairy scalp. 

The following case is reported by M. Langlebert. 1 

Case 4. A student of medicine, who was thoroughly informed upon 
all subjects connected with syphilis, consulted Langlebert for a small 
ulcer behind the corona glandis which he was certain had appeared 
only two days before. The sore was very superficial, scarcely larger 
than the head of a pin, was not indurated, nor accompanied by 
engorgement of the inguinal ganglia. It was cauterized the same 
day with nitrate of silver, and healed in less than a week. 

No induration appeared in the groins, but two months after general 
syphilis declared itself. 

Langston Parker 2 says : " I have destroyed an ulcer thoroughly 
and completely, and all the surrounding tissues, to the depth of half 
an inch, in two hours after the appearance of the chancre, and yet 
bad constitutional symptoms have followed." 

i Moniteur des Hopitaux, Dec. 21, 1858. 

2 Modern Treatment of Syphilitic Diseases, 4th ed., p. 119. 



422 INITIAL LESION OF SYPHILIS. 

It was desirable that thus much should be said in deference to any 
of my readers who may have imbibed their only notions of venereal 
from the teachings of authorities a few years ago ; but the " abortive 
treatment of syphilis" is now so generally recognized to have been 
founded in error, that I need not dilate farther on the subject. 

But if destructive cauterization is inefficacious as a means of pre- 
venting constitutional infection, it is equally unnecessary in most 
cases for the purpose of hastening the cicatrization of the chancre, 
'which rarely tends to spread, and which is commonly sufficiently 
under the control of mercury. I would, therefore, limit its applica- 
tion to those few chancres which are complicated with phagedena, 
and to those cases in which conjugal relations and the necessity of 
secrecy render it desirable to effect cicatrization of the sore as 
speedily as possible in order that coitus may be indulged in with 
comparative safety. When employed, the effect upon the ulcer is ' 
much the same as with the chancroid ; cicatrization is hastened, but 
induration reappears in the wound and general symptoms are devel- 
oped within the normal period. The mode of its application has 
already been described. 

The topical applications to a chancre are absolutely the same as 
those required in the case of a chancroid, and need not be repeated 
here. In the superficial variety, however, which is also the most 
frequent, the degree of ulceration and the amount of the secretion 
are so slight, that the simple interposition between the glans and 
prepuce of a piece of dry lint, or lint soaked in some mild astrin- 
gent, is all that is necessary, and the dressing need not be changed 
oftener than once or twice in the twenty-four hours. 

General Treatment. — The chancre is decidedly under the influence 
of mercury, and presents in this respect a marked contrast to the 
chancroid. Under the use of this mineral reparative action is 
speedily induced, and unless the ulcer be deep and extensive or the 
system much depressed, complete cicatrization may be promised the 
patient in the course of from one to three weeks. 

I do not propose at present to enter fully into the subject of the 
treatment of syphilis, which of course includes the treatment of its 
initial lesion. A few remarks, however, may be better made here 
than elsewhere. And in the first place, let me say that no course 
of mercury administered for a chancre, however thorough or pro- 
longed, is likely to prevent the subsequent evolution of general 
manifestations. I make this statement confidently as the result of 
my own experience and that of others. In the very many attempts 
that I have made to subdue the disease during the existence of the 



TREATMENT. 423 

primary ulcer and prior to the first general manifestation, I have 
never succeeded but in two or three instances, and the great propor- 
tion of failures leads me to suspect the correctness of my diagnosis 
in the few cases of apparent success. Diday's experience coincides 
with my own, and success is such a rarity with Rollet that we find 
him adducing a single instance in confirmation of its possibility. 
Finding, therefore, that such attempts are commonly fruitless, I have 
ceased to undertake them ; and if I use mercury at all for primary 
syphilis, I do it simply for the purpose of healing the ulcer, and stop 
as soon as this object has been accomplished. 

Those cases of chancre in which it may be advisable to administer 
mercury are the following : — 

1. Chancres which, from their size, depth, and progress, occasion 
pain and inconvenience, or which threaten to destroy important 
parts. 

2. Chancres occurring in married persons who cannot long avoid 
sexual intercourse without exciting suspicion. 

3. Chancres in persons who are either too anxious or too unrea- 
sonable to be willing to submit to delay. 

In other cases, especially when the sore is superficial and attended 
with little or no inconvenience, I prefer to delay the use of mercury 
until secondary symptoms appear, meanwhile resorting to tonics, as 
one of the preparations of iron, iodide of potassium or cod-liver oil. 

In using mercurials during this period of syphilis, I commonly 
employ either the blue mass or grey powder ; giving from three to 
five grains twice a day for a week ; increasing the dose at the end 
of that time if, as is rarely the case, there is no perceptible effect 
upon the ulcer ; always avoiding action upon the gums and bowels, 
and suspending treatment as soon as reparative action is established. 
After cicatrization of the sore it is desirable to resort to iodide of 
potassium and iron, in order to combat the chloro-anemia which 
exists in the early stage of syphilis, and thus diminish the severity 
of the premonitory symptoms which usually usher* in secondary 
manifestations. * 



424 INDURATION OF THE GANGLIA. 



CHAPTER III. 

INDURATION OF THE GANGLIA, AND OF THE LYMPHATICS. 

Induration of the Ganglia. — This affection is only met with 
in connection with a chancre, of which it is as necessary an attendant, 
and affords as valuable an indication, as the induration of the base 
of the sore. Of 120 cases of syphilitic erythema, Bassereau found 
that in 116 glandular induration had accompanied the chancre, and 
suppuration took place in a single instance only ; in three alone had 
there been no appreciable changes in the inguinal ganglia. 

Induration of the ganglia is always developed at an early period — 
usually during the first week, and invariably within the first three 
weeks of the existence of the ulcer, and follows the induration of 
its base within a period of a few days. According to Yon Baren- 
sprung, induration of the ganglia appears from ten to twelve days 
after the induration of the point of contagion ; Zeissl says fourteen 
to twenty-one days, and adds, " at all events a short time must be 
allowed before the glands can be affected, and hence before we can 
be sure of the diagnosis of syphilitic infection." . 

The symptoms of glandular induration attendant upon a chancre 
are the following : All the superficial ganglia in one, and generally 
in both groins, become enlarged, and attain the size of a filbert or 
almond. One is frequently found to be more developed than the 
others, which surround it like satellites. This change takes place 
without any symptoms of acute inflammation, and so insidiously 
that the patient may be entirely ignorant of it, and deny its exist- 
ence ; but the surgeon, whos» suspicion has already been excited by 
the induration of the ulcer, on examination of the groin, finds a 
"pleiad" of small tumors, of a cartilaginous hardness, and freely 
movable upon each other and the surrounding tissues. "When firm 
pressure is made upon them, the patient sometimes complains of 
slight tenderness but not of severe pain. They preserve their indo- 
lent character throughout their whole course, and do not become 
inflamed or suppurate unless under the influence of some aggra- 
vating cause, as violence, a strumous diathesis, general cachexia, or 



INDURATION OF THE GANGLIA. 425 

the coexistence of a chancroid or urethritis ; and, unless attended 
by 1 a chancroid, the pus is never inoculable. 

Induration of the ganglia and induration of the base of a chancre 
are in their nature and signification one ; but, as elsewhere remarked,